Primary Care Coding Alert

The key? Know when to use 250.xx and 365.44 Are you always using 250.00 to justify your family physician's diabetes treatments? If so, you should expect the denials to start rolling in. About 18.2 million Americans have diabetes, according to the American Diabetes Association (ADA). To satisfy payers and collect the reimbursement you deserve for treating these patients, specify the type of diabetes the physician treats, coding experts say. Review the following examples and advice to avoid incorrect diabetes coding. 1. Choose the Most Specific Code The single biggest mistake practices make with diabetes coding is always reporting 250.00 as their diagnosis, which indicates uncomplicated diabetes, says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. "Submitting this diagnosis code is particularly problematic if the family physician (FP) is reporting a level-four or -five E/M service, because the uncomplicated diabetes code does not always accurately describe the patient's condition and may not reflect the appropriate degree of attention provided by the physician," she says. Reporting the incorrect diagnosis code is the kind of mistake that can easily lead your carrier to investigate further. Generic code isn't good enough: "CMS, as well as most carriers, will reject any claim submitted with an incomplete ICD-9 code, such as 250," Mulholland says. To avoid this problem, you should encourage your FPs to document whether the diabetes is complicated or not.

Sure, you can easily incorporate the generic code on a superbill, but you can't just leave it at that. "The design of your superbill should provide the physician the opportunity to easily select the most specific fourth and fifth digit," Mulholland says. Nonclinical staff members should never determine the appropriate fourth and fifth digit -- that's up to the physician. 2. Pick Insulin Dependent or Non-Insulin Dependent When you use 250.x (Diabetes mellitus), carry it out to the fifth digit to indicate insulin dependent or non-insulin dependent. ICD-9 defines the fifth digits as follows: 0 -- type II [non-insulin dependent type] [NIDDM type] [adult-onset type] or unspecified type, not stated as uncontrolled
1 -- type I [insulin dependent type] [IDDM] [juvenile type], not stated as uncontrolled
2 -- type II [non-insulin dependent type] [NIDDM type] [adult-onset type] or unspecified type, uncontrolled
3 -- type I [insulin dependent type] [IDDM] [juvenile type], uncontrolled. Reminder: "ICD-9 tells us to use the fifth digit of '2' even if the patient is type II and requires insulin," says Lynn M. Anderanin, CPC, senior coding consultant for Health Info Services in Des Plaines, Ill. Type defines care: The definition of insulin-dependent diabetes is extremely narrow. Therefore, when you code the patient's [...]