DIABETES CODING AND DOCUMENTATION COMPLIANCE

Transcription

1 BC ADVANTAGE AUDIO SERIES: DIABETES CODING AND DOCUMENTATION COMPLIANCE 1 Presented by: Darlene Boschert, RHIA, CPC, CPC-H, CPC-I Providing LOW-COST educational resources for Medical office Professionals

2 2012 NATIONAL DIABETES FACT SHEET Diabetes affects 25.8 million people 8.3% of the U.S. population 18.8 million people in the United States have been diagnosed with diabetes 7 million people are undiagnosed, but likely to have diabetes

3 2012 NATIONAL DIABETES FACT SHEET An additional 79 million people are pre-diabetic Among U.S. residents aged 65 years and older, 10.9 million, or 26.9%, had diabetes in million new cases were identified in people over the age of 20 in betes_fact_sheet.pdf

4 2012 NATIONAL DIABETES FACT SHEET Diabetes can affect many parts of the body and can lead to serious complications Diabetes is the leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness among adults in the United States.

5 2012 NATIONAL DIABETES FACT SHEET Diabetes is a major cause of heart disease and stroke. Diabetes is the seventh leading cause of death in the United States Overall, the risk for death among people with diabetes is about twice that of people of similar age but without diabetes Working together, people with diabetes, their support network, and their health care providers can reduce the occurrence of diabetes complications

6 DIABETES MELLITUS CODING What you need to know to code Diabetes: Type of Diabetes Controlled or Uncontrolled Complications or Manifestations If the type of diabetes mellitus is not documented in the medical record the default is type II

7 CODING UNCONTROLLED DM ( OR ) Acceptable terms- uncontrolled, out of control, not controlled. Poor control, suboptimal control, inadequate control, poorly controlled are vague terms and do not describe uncontrolled blood sugar levels. Poor control do not code as uncontrolled Inadequate control do not code as uncontrolled - Out of control 250.x2 250.x3 249.x1

8 DIABETES COMPLICATIONS DM code without mention of complications, is appropriate at times, however if complications exist, code to the specific complication and manifestations 250.4x Diabetes with renal manifestations 250.5x Diabetes with ophthalmic manifestations 250.6x Diabetes with neurological manifestations 250.7x Diabetes with peripheral circulatory disorders 250.8x Diabetes with other specified manifestations Category 250 classifies diabetes mellitus which is further subdivided to identify the presence or absence of complication and/or manifestation of the diabetes (fourth digit). The fifth digit identifies the type of diabetes (type I or type II) and the current state of controlled versus uncontrolled.

9 THE RESULT OF COMPLETE, ACCURATE, AND COMPREHENSIVE CODING DX Description Estimate Cost of Care Diabetes w/ no complications $1, X Diabetes w/ ophthalmic manifestations $2, X Diabetes w/ acute complications $2, X 250.8X 250.4X or 250.7X Diabetes w/ neurologic manifestations or other specified manifestations Diabetes w/ renal or peripheral circulatory manifestations $3,527 $4,391

10 DIABETIC TRIOPATHY The term diabetic triopathy refers to the presence of nephropathy, neuropathy and retinopathy in a diabetic patient. Diabetic complications/manifestations are paired codes. Assign as many codes from 250.x as needed to identify all of the complications that the patient has followed by a code for the associated manifestation indicating the complication Example: Diabetes with neurological manifestations Polyneuropathy in diabetes Diabetes with Renal manifestation Diabetic Nephropathy Diabetes with Ophthalmic manifestation Diabetic Retinopathy, NOS

11 DIABETIC COMPLICATIONS: ESTABLISHING A CAUSE AND EFFECT RELATIONSHIP Coding Guidelines require that you establish a cause-and-effect relationship with words such as due to, secondary to, caused by : Chronic Kidney Disease due to diabetes Peripheral Vascular Disease secondary to diabetes Neuropathy caused by Diabetes The preferred method: Diabetic CKD, Diabetic PVD, Diabetic Neuropathy, Captures a more complete picture of a patient s overall health and potential needed treatments

12 DIABETIC COMPLICATIONS: PAIRED CODES Diabetes categories 250.4X, 250.5X, 250.6X, 250.7X, some of 250.8X and secondary diabetes mellitus categories 249.4X, 249.5X, 249.6X, 249.7X, and some of 249.8X require an additional code to be used, and the acceptable codes for use with each category are listed in the ICD-9-CM Tabular List. For all of these you must code both the diabetes with manifestations code as well as the code for the specified manifestation

13 DIABETIC COMPLICATIONS: PAIRED CODES If the physician documents Diabetes with peripheral circulatory disorders he/she also needs to indicate what that circulatory disorder is and demonstrate the link to the diabetes. With the Electronic Medical Record (EMR) and automatic coding systems, physicians sometimes include the wording verbatim from the ICD-9-CM book for the diabetes code, but omit documenting the complication. In this example, the manifestations were not documented, therefore cannot be coded.

14 DIABETES COMPLICATIONS Complications from Diabetes: ICD-9 provides codes when a causal relationship exists and is documented between a condition and the diabetes Ex: Nephropathy due to Diabetes or Diabetic Nephropathy and Documentation: Must support this causal relationship When a causal relationship exists, the diagnosis code assigned is 250.xx, followed by the code for the manifestation/complication Without the causal relationship: Ex: Diabetes written on one line and Nephropathy on another would be coded (Diabetes) and (Nephropathy, not in a diabetic)

15 DIABETES COMPLICATIONS: EXAMPLE 48-YO with Diabetic polyneuropathy and peripheral angiopathy due to Type II diabetes mellitus who presented for routine follow up where DM, polyneuropathy and angiopathy were all addressed in documentation Should be coded as: Diabetes with neurological manifestations Polyneuropathy in diabetes Diabetes with peripheral circulatory disorders Peripheral angiopathy in diseases classified elsewhere

16 DIABETES COMPLICATIONS Diabetic Neuropathy requires two codes: , Diabetic PVD , Diabetic Nephropathy , or if CKD then code the depending on the stage of CKD Diabetic Retinopathy , If Proliferative Diabetic Retinopathy code ,

17 EXCEPTION TO THE RULE: HOG H Hypoglycemia, O Osteomyelitis and G Gangrene are exceptions to the rule. There is an assumed relationship between these conditions and diabetes unless there is documentation that specifically indicates that these conditions are due to something other than diabetes.

18 QUIZ If a patient has gangrene and is also a diabetic, is the gangrene always coded as a diabetic complication?

19 ANSWER If no other "cause and effect" relationship has been established for the gangrene, assume that the gangrene is the consequence of a , Diabetic peripheral vascular circulatory disorder and add code 785.4, Gangrene This is especially true when the gangrene is of the lower extremity. If there is a history of trauma, such as an open wound that became infected and progressed to gangrene, code it as: Open wound, complicated and add codes 785.4, Gangrene and , Diabetes ICD-9 Coding Clinic, Vol 3 No 2, Mar-Apr 1986

20 DIABETES COMPLICATIONS: OSTEOMYELITIS If the physician indicates diabetic osteomyelitis, or if the patient has both diabetes and acute osteomyelitis and no other cause of the osteomyelitis is documented, it would be appropriate to assign codes: , Diabetes with other specified manifestations, Type II, or unspecified type, not stated as uncontrolled, and 731.8, Other bone involvement in diseases classified elsewhere, and 730.0X, Acute osteomyelitis ICD-9-CM assumes a relationship between diabetes and osteomyelitis when both conditions are present. Coding Clinic, Vol 21 No 1, 1st Qtr 2004

21 DIABETIC ULCER VS. WOUND Ulcers of the lower extremities, particularly of the feet, commonly present as a complication of diabetes. They may result from either diabetic neuropathy or diabetic peripheral vascular disease, however, it is important to recognize that not all ulcers in diabetic patients are diabetic ulcer. A direct causal relationship between the diabetes and the ulcer must be documented Ex: Ulcer due to diabetes or diabetic ulcer If the patient has an ulcer or diabetic ulcer, do not document it as a wound!

22 ULCER OF SKIN Diabetic Ulcer vs. Wound 707.0x Chronic ulcer of skin ULCERS OF SKIN Pressure ulcer (bedsore or decubitus ulcer) due to prolonged pressure: 707.0x Use additional code to identify the pressure ulcer stage: The 5th digit indicates site Ex: Pressure ulcer of buttocks: x Ulcer of lower limbs (except pressure ulcer) 5 th digit indicates site Code first any associated underlying condition Ex: Atherosclerosis of extremities w/ulceration: Ex: Diabetes mellitus: , Add as an additional code when gangrene is present Stasis ulcers are ordinarily due to varicose veins of the lower extremities and are coded to category 454.x

23 SECONDARY DIABETES MELLITUS- 249.XX Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug or poisoning) Note there is no Type I or Type II codes, but a 5th digit is required to identify whether the diabetes is controlled or uncontrolled Postpancreatetomy DM assign code 251.3, post surgical hypoinsulinemia, also assign a code from subcategory 249 and code V88.1x, acquired absence of pancreas, as additional codes For patients who routinely use insulin, code V58.67

24 PAST MEDICAL HISTORY DOCUMENTATION Best Practice: If there is no support in the current note for the condition, it should not be coded! Past Medical History Some diabetes manifestations do not go away; however, coding from past medical history without current support for the condition is not acceptable. For example, some of today s EMRs auto-populate information into various fields in the progress note to make it easier for physicians to document that day s visit. However, some of these systems simply take any condition which was ever coded and automatically place it into past medical history, whether these conditions were reviewed or not. This is further complicated by the possibility that the condition when originally coded may not have been coded correctly and may have been coded years prior.

25 CODING CLINIC QUESTION Volume 29 No. 1, 1st Quarter 2012 Since our facility has converted to an electronic health record, providers have the capability to list the ICD-9-CM diagnosis code instead of a descriptive diagnostic statement. Is there an official policy or guideline requiring providers to record a written diagnosis in lieu of an ICD-9-CM code number?

26 CODING CLINIC ANSWER Yes, there are regulatory and accreditation directives that require providers to supply documentation in order to support code assignment. Providers need to have the ability to specifically document the patient s diagnosis, condition and/or problem. Therefore, it is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. ICD-9-CM is a statistical classification, per se, it is not a diagnosis. Some ICD-9-CM codes include multiple different clinical diagnoses and it can be of clinical importance to convey these diagnoses specifically in the record. Also some diagnoses require more than one ICD-9-CM code to fully convey. It is the provider s responsibility to provide clear and legible documentation of a diagnosis, which is then translated to a code for external reporting purposes

27 QUESTION Volume 29 No.1, 1 st Quarter 2012 Coders are confused as to the correct coding of borderline diagnosis. The advice published in Coding Clinic, First Quarter 2011, pages 9-10, appears to be contradictory. The advice instructs coders to assign code 416.8, Other chronic pulmonary heart diseases, for borderline pulmonary hypertension as if it were confirmed; however, a diagnosis of borderline diabetes without further confirmation of the disease is assigned to code , Abnormal glucose. Should code 793.2, Nonspecific (Abnormal) findings on radiological and other examination of body structure, Other intrathoracic organ, be assigned for a diagnosis of borderline pulmonary hypertension or should all borderline diagnoses require clarification from the attending physician so that the appropriate code may be reported?

28 ANSWER: Borderline diagnoses are coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-9-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient). Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.

29 BORDERLINE DIABETES MELLITUS Borderline Diabetes and Pre-Diabetes are terms used to describe blood sugar levels that are higher than normal Code to Abnormal glucose, NOS Pre-diabetes, NOS Hyperglycemia, NOS

30 INSULIN PUMP MALFUNCTION 1.C.3.a.6.b ICD-9-CM Official Guidelines Overdose of insulin due to insulin pump failure The principal or first listed code for an encounter due to an insulin pump malfunction resulting in an overdose of insulin, should also be , Mechanical complication due to insulin pump, followed by code 962.3, Poisoning by insulins and antidiabetic agents, and the appropriate diabetes mellitus code based on documentation

31 THANK YOU FOR LISTENING TODAY. QUESTIONS? 31