Primary Care Coding Alert

Question: An established patient with type II diabetes reported to the FP complaining of a headache and neck pain. The physician performed a level-four E/M service, including a CT scan and a check of blood sugar, prescribed some pain medication and gave the patient a dose of glucophage because he had missed his morning pill. Should we include a diagnosis code for diabetes?

Missouri Subscriber

Answer: It depends on the situation. Diabetes is a chronic condition, and you should only report ICD-9 codes for chronic conditions when they are relevant to the service the physician provides. In your scenario, the physician clearly considered the diabetes, as evidenced by the fact that he checked the patient's blood sugar and gave the patient a dose of glucophage. Accordingly, you should:

• report 99214 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the E/M.
• link 784.0 (Headache) to 99214 to represent the patient's headache.
• link 723.1 (Cervicalgia) to 99214 to represent the patient's neck pain.
• link 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) to 99214 to represent the diabetes.
  

But if the diabetes does not affect the physician's treatment options or is otherwise not addressed during the encounter, you should report 99214 for the E/M -- with 784.0 and 723.1 linked to 99214.

Also, don't forget to code for the CT scan and blood sugar check, to the extent your practice provided those services to the patient