Diabetes Coding. (Featured CME Topic: Diabetes Mellitus).

Beyond the human suffering, disability, and loss of life that result, diabetes costs the United States about $100 billion a year in direct and indirect costs. (1) The full cost of diabetes is difficult to measure. Death records often fail to reflect the role of diabetes because ICD-9 coding rules call for the assignment of a single cause of death, which may overlook some medical conditions--such as diabetes--that may have played a role in the death but that were not sufficiently significant to be considered the actual cause of death. The costs related to undiagnosed diabetes are unknown.

Improving nutrition and increasing physical activity are ways to delay the progression of diabetes. Other ways known to help are controlling blood glucose levels and improving access to proper medical treatment. As of October 2001, 46 states have some types of laws requiring health insurance coverage to include treatment for diabetes. (2)

The National Center for Health Statistics (NCHS) is the Federal Government's principal vital and health statistics agency. Since 1960, the agency has provided a wide variety of data with which to monitor the nation's health. The physician has the opportunity to provide more complete and more accurate data for analysis through quality documentation and correctly coded claim form submission. Correct diagnosis coding of diabetes is critical to appropriate payment for services. It is also provides sound authority to support the future financing of healthcare.

Physicians are responsible for the accuracy and completeness of the information submitted on a bill. The Health Insurance Portability and Accountability Act (HIPAA) requires the use of ICD-9-CM and its Official ICD-9-CM Guidelines for Coding and Reporting by most health plans (including Medicare) by October 16, 2002. The ICD-9-CM Coding Guidelines for Outpatient Services, which is part of the Official ICD-9-CM Guidelines for Coding and Reporting, provides guidance on diagnosis coding specifically for outpatient facilities and physician offices.

ICD-9-CM diagnosis codes are composed of codes with 3, 4, or 5 digits. Codes with three digits are included as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth. digits to provide greater specificity (Table). Assign the codes for both the manifestation and underlying cause; code first the underlying disease. The codes for manifestations cannot be used (designated) as principal diagnosis. Conditions that are integral to the disease process should not be assigned as additional codes.

There has been some confusion about the meaning of "highest degree of specificity" and "reporting the correct number of digits." In the context of ICD-9-CM coding, the highest degree of specificity refers to assigning the most precise ICD-9-CM code that most fully explains the narrative description of the symptom or diagnosis. An example follows: A patient is referred to a physician with a diagnosis of diabetes mellitus. However, there is no indication that the patient has diabetic complications or that the diabetes is out of control. It would be incorrect to assign code 250 since all codes in this series have five digits. Reporting only three digits of a code that has five digits would be incorrect. One must add two more digits to make it complete. Because the type of diabetes (adult onset/juvenile) is not specified, and there is no indication that the patient has a complication or that the diabetes is out of control, the correct ICD-9-CM code would be 250.00. The fourth and fifth digits of the code would va ry depending on the specific condition of the patient. One should be guided by the code book. (3)

MEDICARE INFLUENZA/PNEUMOCOCCAL VACCINATION BENEFITS COVERAGE

People with diabetes are about three times as likely to die with flu and pneumonia than people without diabetes. During flu epidemics, diabetic patients are six times as likely to go to the hospital. (4) Diabetic patients should receive a pneumococcal vaccine (PPV) and an annual flu shot. Influenza vaccines are typically administered once a year. PPV vaccines are typically administered once in a lifetime to persons at high risk of pneumonia infection. Medicare no longer requires that a doctor of medicine or osteopathy orders the vaccines for either flu or PPV coverage purposes.

Medicare Part B began paying for influenza virus vaccines in 1998 and PPV in 1981. Coverage of the vaccines and their administration is available only under Medicare Part B regardless of the setting in which they are furnished. Medicare beneficiaries who get the vaccines do not pay the usual coinsurance or deductible amounts. Medicare pays those amounts, along with an amount for the vaccine and an additional amount for administering the shot.

If a physician sees a patient for the sole purpose of administering a flu or PPV vaccination, the physician may bill only for the administration and vaccine. However, if a patient actually receives reasonable and medically necessary services constituting an "office visit" level of service, the physician may bill for the visit, the vaccine, and the administration of the vaccine. The following diagnosis codes are appropriate for use when billing Medicare patients for flu and/or PPV:

* Influenza virus vaccine is billed using diagnosis code V04.8

* PPV is billed using diagnosis code V03.82.

One of the following procedure codes is appropriate for use when billing Medicare patients for influenza virus vaccine (the codes are not interchangeable):

* 90657 Influenza virus vaccine, split virus, 6-35 months' dosage, for intramuscular or jet injection use

* 90658 Influenza virus vaccine, split virus, 3 years and above, for intramuscular or jet injection use

* 90659 Influenza virus vaccine, whole virus, for intramuscular or jet injection use.

The appropriate CPT code used to bill Medicare patients for PPV vaccination is:

* 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult dosage, for subcutaneous or intramuscular use.

The previously mentioned CPT codes are for vaccine only and do not include administration. The appropriate HCPCS code to use for administration of the vaccination is:

* G0008 Administration of influenza virus vaccine

* G0009 Administration of pneumococcal vaccine. (3)

References and Suggested Reading

(1.) World Diabetes Day, Statement by HHS Secretary Tommy G. Thompson, 2001. http://www.hhs.gov/news/press/200lpres/20011114.html.

(2.) State Laws Mandating Diabetes Health coverage. 2001. http://www.ncsl.org/programs/health/diabetes.htm

(3.) Attachment, coding clinic for ICD-9-CM (1st Qtr 2000). American Hospital Association 

(4.) ICD-9-CM coding for Diagnostic Tests. Department of Health & Human Services centers for Medicare & Medicaid Services. Program Memorandum Transmittal AB-01-144. September 26, 2001. http://www.hcfa.gov/pubforms/transmit/AB01144.pdf

(5.) Centers for Disease Control and Prevention. Flu and pneumonia shots can be lifesavers for people with diabetes. www.cdc.gov/diabetes

(6.) Centers for Medicare & Medicaid Services. 2001 Fact Sheet for Medicare Influenza/Pneumococcal Vaccination Benefits. www.hcfa.gov/quality/3g5.htm

(For the latest ICD-9-CM coding guidelines, refer to the following website: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm#guide)

TABLE.

Diabetes Codes for 2002

Diabetes mellitus 250

EXCLUDES: gestational diabetes (648.8)
          hyperglycemia NOS (790.6)
          neonatal diabetes mellitus (775.1)
          nonclinical diabetes (700.2)



Fourth digit classification for use with category
250 Diabetes mellitus:

  250.0 Diabetes mellitus without mention of complication
        [or manifestation classificable to 250.1-250.9]

  250.1 Diabetes with ketoacidosis
        [Diabetic acidosis without mention of coma]
        [Diabetic ketosis without mention of coma]

  250.2 Diabetes with hyperosmolarity
        [Hyperosmolar (nonketotic)coma]

  250.3 Diabetes with other coma
        Diabetic coma (with ketoacidosis)
        Diabetic hypoglycemic coma
        Insulin coma NOS
        EXCLUDES: diabetes with hyperosmolar coma (250.2)

  250.4 Diabetes with renal manifestations
        Use additional code to identify manifestation, as:
          Diabetic neuropathy NOS (583.81)
          Diabetic nephrosis (581.81)
          Intercapillary glomerulosclerosis (581.81)
          Kimmeistiel-Wilson syndrome (581.81)

  250.5 Diabetes with ophthalmic manifestations
        Use additional code to identify manifestation, as:
          Diabetic blindness (369.00-369.9)
          Diabetic cataract (366.41)
          Diabetic glaucoma (365.44)
          Diabetic retinal edema (362.83)
          Diabetic retinopathy (362.01-362.02)

  250.6 Diabetes with neurological manifestations
        Use additional code to identify manifestation, as:
          Diabetic amyotrophy (358.1)
          Diabetic mononeuropathy (354.0-355.9)
          Diabetic neurogenic arthropathy (713.5)
          Diabetic peripheral autonomic neuropathy (337.1)
          Diabetic polyneuropathy (357.2)

  250.7 Diabetes with peripheral circulatory disorders
        Use additional code to identify manifestation, as:
          Diabetic gangrene (785.4)
          Diabetic peripheral angiopathy (443.81)

  250.8 Diabetes with other specified manifestations
          Diabetic hypoglycemia
          Hypoglycemic shock
            Use additional code to identify manifestation, as:
              any associated ulceration (707.10-707.9)
              diabetic bone changes (731.8)
            Use additional E code to identify cause, if drug induced

  250.9 Diabetes with unspecified complications

The following fifth-digit subclassification is for use with
category 250:

  0 type II [non-insulin dependent type] [NIDDM type] [adult-onset type]
          or unspecified type, not stated as uncontrolled Fifth-digit
          0 is for use for type II, adult-onset diabetic patients, even
          if the patient requires insulin

  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
          Fifth-digit 2 is for use for type II adult-onset diabetic
          patients, even if the patient requires insulin

  3 type I [insulin-dependent type] [IDDM] [juvenile type], uncontrolled