Pediatric Coding Alert

Don't overlook digits four and five when assigning ICD9 codes for diabetes diagnoses these last-but-not-least numbers could be crucial to ensuring proper reimbursement for services provided to pediatric diabetes patients.

Indeed, every pediatrician in general practice is involved in some way with treating diabetes. Accurately reporting diagnosis and procedure codes for pediatric patients with diabetes mellitus (DM) depends on selecting the correct fourth and fifth digits for ICD-9 codes in the 250.xx series and using the appropriate CPT codes for in-office testing and the services the physician performs in managing this chronic condition.

Choosing an ICD-9 code at the highest level of specificity is especially important when reporting diagnoses for children with special needs, such as pediatric DM patients, coding experts say. Documentation for these ICD-9 codes supports the higher-level E/M codes that pediatricians use to report complex services provided to chronically ill patients.

(Upcoming editions of Pediatric Coding Alert Extra will address the spectrum of CPT codes available for children with special needs.)

Pediatricians may use glucose tolerance tests (GTT) to confirm DM diagnoses, but before reporting test codes, you'll need to consider whether your practice has waived status to perform these tests under the Clinical Laboratories Improvement Act (CLIA). If, like most pediatricians, you have only waived status, do not use any code that requires a higher-level certification, coding consultants advise.

Many pediatric groups have waived status for GTT and can report blood glucose test codes, says Shirley Fullerton, CMBS, CPC, CPC-H, academic director for the Medical Association of Billers in Las Vegas and a coder for MedQuist, a national Internet coding and transcription company based in New Jersey.

When the physician or nurse collects three blood specimens and administers glucose, report 82951 (Glucose; tolerance test [GTT], three specimens [includes glucose]), Fullerton says. For each additional specimen more than three, use 82952 (... tolerance test, each additional beyond three specimens).

If the physician uses a glucometer to measure blood glucose levels, bill 82962 (Glucose, blood by glucose monitoring device[s] cleared by the FDA specifically for home use).

Remember that if you are reporting CLIA-waived test codes to Medicare, you must append modifier -QW (CLIA waived test), Fullerton says.

Blood specimen collection is not bundled with the GTT codes and can be reported separately, according to the February 2001 CPTAssistant. Since most physicians collect specimens from pediatric DM patients with finger sticks, bill 36416 (Collection of capillary blood specimen [e.g., finger, heel, ear stick]).

You must select both a fourth and fifth digit to use with 250.xx (Diabetes mellitus) series codes, according to ICD-9. Use the fourth digit to identify complications, such as renal, ophthalmic, neurological and circulatory disorders. Fourth digits range from 0 (Diabetes mellitus without mention of complication) to 8 (Diabetes with other specified manifestations).

Often, diabetic patients develop several complications, and physicians are unsure which codes to use on the encounter form, says Jerome S. Fischer, MD, a board-certified internist and endocrinologist at Diabetes and Glandular Disease Clinic in San Antonio and the author of Diabetes Care Documentation and Coding for Clinicians, published in 2002 by the American Diabetes Association (ADA).

"If the complications affect the kidneys, eyes, nerves or peripheral circulation, then you should also use additional codes to identify the actual manifestation," says Karen M. Beard, CPC, a senior associate at Medical Management Associates Inc. in Atlanta.

"List only the complications that were addressed at a particular visit," Fischer says. For instance, if a Type I pediatric patient with vision problems is seen in the office after a hypoglycemic incident, you would link 250.8x (Diabetes with other specified manifestations) rather than 250.5x (Diabetes with ophthalmic manifestations) to the appropriate office visit code (99201-99215) because the reason for the visit was hypoglycemia.

Choose a fifth digit to describe the type of diabetes the patient has and to indicate whether the condition is controlled or uncontrolled.

To eliminate any confusion, coders should show physicians the 250.xx section of the ICD-9 text and go over these codes with the physicians to make them aware of how DM is defined and to what level of specificity, says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. "The physicians then have a better understanding of the types of DM cases they treat, based on the ICD-9 listings." Also, you should update your practice's superbill to reflect these code descriptions, she adds.

ICD-9 lists the following fifth-digit choices for the 250.xx series: