Primary Care Coding Alert

Distinguish between tests, Dx codes, with these pro coding tips.

When the Centers for Disease Control and Prevention (CDC) announces that one in three adults has prediabetes, you know that you will be called on to code the condition on a frequent basis (Source:  www.cdc.gov/diabetes/basics/prediabetes.html).

That’s why we’ve assembled this four-step guide to coding prediabetes, including all the diagnosis and procedure codes you will need before and after your provider arrives at a definitive diagnosis.

Step 1: Understand How to Code Risk Factors

Before your provider arrives at a diagnosis of R73.03 (Prediabetes) for a patient, the patient will present with one or more risk factors that you will need to code. Some of the more typical, according to the CDC, include:

• Being overweight, which you would document with a code from E66.- (Overweight and obesity) along with an additional code from Z68.- (Body mass index [BMI]) if known per the ICD-10 note accompanying E66.-.
• Having a parent, brother, or sister with type 2 diabetes, which you would document with Z83.3 (Family history of diabetes mellitus).
• Being physically active less than three times a week, which you could code with Z72.3 (Lack of physical exercise).
• A history of gestational diabetes (diabetes during pregnancy), which you could code with Z86.32 (Personal history of gestational diabetes), or giving birth to a baby who weighed more than 9 pounds.
• Having polycystic ovary syndrome, which you would code with E28.2 (Polycystic ovarian syndrome).

Step 2: Understand the Test Codes

Once your provider determines that the patient’s risk factors could lead to prediabetes, he or she could either perform or order one of a number of possible tests. Each of them measures the patient’s blood sugar level over a given period of time in a different way:

• 83036 (Hemoglobin; glycosylated (A1C))
• 83037 (Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use)
• 82947 (Glucose; quantitative, blood (except reagent strip))
• 82950 (Glucose; post glucose dose (includes glucose))
• 82951 (Glucose; tolerance test (GTT), 3 specimens (includes glucose))
• 82948 (Glucose; blood, reagent strip)
• 82962 (Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use).

“The most common test is the glycosylated hemoglobin, or A1C [83036 and 83037], which provides a 3-month window into the blood sugars of the patient,” explains Sheri Poe Bernard, CPC, CRC, CDEO, CCS-P, author of the AMA book, Risk Adjustment Documentation and Coding. Of the other tests, “the blood glucose test [82947] will measure the sugar in blood for a snapshot in time, and a glucose tolerance test [82950 and 82951] looks at what an uptake of simple sugars does to your blood sugar levels for the hours that follow ingestion,” Bernard adds.

The other tests, 82948 and 82962, are finger stick tests that test the patient’s current blood sugar level.

Pro Coding Tip 1: “You would not use code 82962 if a finger stick is done in the office on a device not approved for home use,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. “This code is reserved for glucose testing that has been monitored via an FDA-approved device that may be used in the patient’s home, although if such a device is used in the office, 82962 may still be reported. A finger stick performed with a device that is not FDA-approved for use in the home is submitted with code 82948 instead” adds Hauptman.

Pro Coding Tip 2: “Keep in mind that just because a test has a code does not mean all payers will reimburse; you should know the individual payer’s guidelines,” Hauptman continues. “For example, doctors will often review the results pulled for home monitoring devices, and this would be incorporated into the medical decision making of the evaluation and management [E/M] service submitted,” advises Hauptman.

Step 3: Understand the Blood Sugar Levels

While your provider will determine the patient’s prediabetes diagnosis, the following table will help you understand how your physician will arrive at the decision:

(Source:  www.cdc.gov/diabetes/basics/getting-tested.html).

So, for example, if your provider orders an A1C for the patient, “a patient with prediabetes will be over a 5.7 percent blood sugar threshold,” explains Hauptman. “And if a patient’s fasting blood sugar is over 100 after a blood glucose test such as 82947, this is a definite sign that something is going on and needs to be addressed,” Hauptman adds.

Step 4: Understand Dx Codes

Along with the testing, you should also code Z13.1 (Encounter for screening for diabetes mellitus) if your provider is performing the test. And if your provider determines that your patient does have prediabetes, you’ll assign R73.03 during the follow-up visit when your provider discusses any test results and treatment options with the patient.

Pro Coding Tip 3: “R73.03 has only been a code for three years,” Bernard reminds coders. Prior to 2016, “prediabetes was reported as R73.09 [Other abnormal glucose],” Bernard adds, so it is important that you use R73.03 if your provider documents that the patient does, indeed, have the condition.