Pathology/Lab Coding Alert

Think you can't bill Medicare for 2 screenings per year? Think again

Fact: The United States spends $100 billion per year on direct and indirect health costs related to diabetes. With lab testing for diagnosis and monitoring a significant part of that expense, you can't afford any diabetes coding mistakes.

Get the truth behind six myths that could be eating your diabetes reimbursement from Sheri Bernard, CPC, CPC-H, CPC-P, vice president of member relations with the American Academy of Professional Coders.

Myth 1: You can bill Medicare for only one diabetes screening per year.

Fact: Medicare pays for two diabetes screening tests per year if the patient has significant risk factors such as pre-diabetes or dysmetabolic syndrome X (277.7), Bernard says. You should be seeing this diagnosis code a lot because there are approximately 41 million pre-diabetics in this country.

You can't use 277.7 unless the doctor documents three of the following, Bernard says:

• abdominal obesity
• hypertension
• fasting glucose of 110 or higher
• high triglycerides in cholesterol (bad cholesterol)
• low HDL in cholesterol (good cholesterol).

Don-t: You shouldn't assign 277.7 as the diagnosis automatically if you see three or more of these factors in the record. Ask the doctor first. Also, don't use the screening code if the patient has had a diagnosis of diabetes in the past, or if the patient has acute symptoms and the screening isn't -routine.-

When billing screening tests 82947 (Glucose; quantitative, blood [except reagent strip]), 82948 (Glucose; blood, reagent strip) or 82950 (Glucose; post glucose dose [includes glucose]), make sure to attach modifier QW (CLIA waived test) for labs operating with a certificate of waiver under the Clinical Laboratory Improvement Amendments.

Also, don't forget to append modifier TS (Follow-up service) if the test is a follow-up for a pre-diabetic

patient. The absence of modifier TS is a big reason carriers deny twice-yearly screenings for 277.7 patients.

Also: Make sure to bill 36415 (Collection of venous blood by venipuncture) and include diagnosis code V77.1 (Special screening for diabetes mellitus).

Watch for Complications and Medications

Myth 2: If the physician orders lab tests because of a diabetes complication, you should always sequence the diabetes diagnosis code (250.xx) first.

Fact: There are a few exceptions to that rule, Bernard says. You should report the diabetes code secondarily only in case of:

• insulin pump malfunction
• heart problems
• cerebrovascular problems
• decubitus ulcer.

Myth 3: If the patient is taking insulin, you need to list V58.67 (Long-term [current] use of insulin) for continuing use only.

Fact: Use V58.67 only when a type II diabetes patient is taking insulin long-term. You don't need this V code for type I diabetes diagnosis codes because those patients are always taking insulin long-term, Bernard says.

Manifestation and Late-Effects Can Show Medical Necessity for Lab Tests

If the physician orders lab tests for a condition that is a manifestation or late effect of diabetes, you can't ignore the diabetes connection to show medical necessity.

Myth 4: Because there are only four lines on the claim, you can leave out 250.xx if you-re reporting a manifestation diagnosis code specific to diabetes.

Fact: You still need to include the 250.xx code because it identifies whether the diabetes is type I or type II, and controlled or uncontrolled, Bernard says. The good news is that the new claim form has eight blanks. The bad news is your software still may have only four.

Myth 5: When your code for a manifestation of diabetes, the descriptor must have the word -diabetes- in it.

Fact: The descriptor for the manifestation of diabetes doesn't need to contain the word -diabetes.-

Example: You should pair 250.40 (Diabetes with renal manifestations; type II or unspecified type, not stated as uncontrolled) with 583.81 (Nephritis and neuropathy, not specified as acute or chronic, in diseases classified elsewhere). And you should pair 250.60 (Diabetes with neurological manifestations; type II or unspecified type, not stated as uncontrolled) with 536.3 (Gastroparesis).

Myth 6: If a diabetic patient receives a successful pancreas transplant and no longer needs insulin injections, you never report a diabetes code after this -cure.-

Fact: There are circumstances when you should code for diabetes in this post-transplant patient, such as anytime the medical record documents diabetes or anytime the diabetes is responsible for a complication, such as long-standing or newly diagnosed retinopathy, renal disease or neuropathy. These are examples of complications caused by the diabetes that the transplant has -cured.-

-If the patient has a -late effect- condition as a result of the pancreas transplant even though it appeared to be successful,- then you would still need to apply the diabetes code as a secondary code, says George Ward, billing/accounting supervisor with South of Market Health Center in San Francisco.

Don't forget: Also report V42.83 (Organ or tissue replaced by transplant; pancreas) for a pancreas replaced by transplant.