Diabetic Complications: Diagnosis, Documentation, Coding, and Compliance

Transcription

1 Diabetic Complications: Diagnosis, Documentation, Coding, and Compliance Richard D. Pinson, MD, FACP, CCS Principal and Medical Director Pinson and Tang, LLC CDI Educators and Consultants Houston, TX 1 Learning Objectives At the completion of this educational activity, the learner will be able to: Explain the regulatory requirements for coding HCCs Recognize the diabetic complications that affect risk adjustment Identify diagnostic criteria for diabetic complications 2

2 Richard Pinson, MD, FACP, CCS Physician, educator, and healthcare consultant Practiced internal medicine and emergency medicine for 25 years Trained thousands of physicians, documentation specialists, and coders nationwide Coauthor of the CDI Pocket Guide, the Outpatient CDI Pocket Guide: Focusing on HCCs, and the Pocket Guide for Coding Professionals Author of monthly Coding Corner column for the American College of Physicians ACP Hospitalist magazine for over 8 years 3 Agenda 1. Introduction to HCCs 2. Outpatient Coding Guidelines 3. CMS billing requirements 4. Diabetic complications Hyperglycemia Hypoglycemia Arthropathy Circulatory Hyperlipidemia Kidney Neuropathy Oral Osteomyelitis Retinopathy/ocular Skin 4

3 What Are HCCs? HCCs are designed to group patients that are clinically similar and with similar long term costs Large majority are chronic conditions Captured in both inpatient and office settings Used as both a payment methodology and a diagnostic classification for risk adjustment 2 sets of HCCs: 83 CMS HCCs for Medicare Advantage plans 115 HHS HCCs for ACA plans 5 Inpatient vs. Physician Practice Inpatient Long visit Payment based on diagnosis/drg Inpatient coding guidelines Documentation requirements Meet OCG Section III secondary diagnosis guideline Physician practice Short visit Payment based on E/M level, not diagnosis Outpatient coding guidelines Documentation requirements OCG Section IV: Must be relevant to encounter and addressed during the visit 6

4 Official Coding Guidelines Inpatient OCG Section III Definition of Additional Diagnosis: clinical evaluation, treatment, diagnostic procedures, increased nursing care/monitoring, or extended LOS. Outpatient OCG Section IV Documented condition must be directly relevant to or affect the specific encounter. The term addressed best describes this requirement. 7 Official Coding Guidelines: Outpatient Section II, Principal Diagnosis and Section III, Other (Secondary) Diagnoses do not apply to outpatient For inpatient only Section I, Conventions / General and Chapter Specific Guidelines does apply to both outpatient and inpatient IV.I: Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s). IV.J: Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. 8

5 Official Coding Guidelines: With Section I.A.15 The classification presumes a causal relationship between two conditions linked by with or in in the Alphabetic Index or Tabular List These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated Coding Clinic, 2nd Quarter 2018, p. 6 The with guideline does not apply to any term listed in the Index as NEC (not elsewhere classified) Assume a causal relationship for any term listed as with but no NEC designation Examples: Linked: Diabetes type 2 with osteomyelitis (E11.69) Not linked: Diabetes type 2 with arthropathy NEC (E11.618) 9 Key Chronic HCC Diagnoses Abdominal aortic aneurysm, aortic atherosclerosis Alcohol/drug abuse, dependence Amputation status Cardiac dysrhythmia Cardiomyopathy Chronic kidney disease Chronic respiratory failure COPD Depression Diabetic complications Heart failure Morbid obesity/bmi Paralysis (plegia/paresis) Malnutrition Neoplasms Pulmonary hypertension & heart disease Skin ulcers 10

6 Diagnosis of Diabetes HbA1c > 6.5%, or FBS > 125 mg/dl, or 2 hour OGGT > 200 mg/dl, or Random glucose > 200 mg/dl + symptoms 11 Types of Diabetes Type 1 (E10) juvenile ; deficient insulin production Type 2 (E11) adult ; peripheral insulin resistance high insulin production islet cell burnout Underlying medical condition (E08) cystic fibrosis, chronic pancreatitis, others Drugs/chemical toxins (E09) steroids; dioxin pesticide Other specified (E13) e.g., genetic deficiencies; postprocedural; Type 1.5 Pregnancy (O24) gestational or preexisting by type 12

7 Diabetic Complications Acute (HCC ) Hyperglycemia Hypoglycemia Ketoacidosis (DKA) Hyperglycemic hyperosmolar state (HHS) Chronic (HCC ) Arthropathy Circulatory complications Hyperlipidemia Kidney complications Neuropathy Oral Osteomyelitis Retinopathy/ocular Skin 13 Hyperglycemia (E11.65) Blood sugar > 140 mg/dl Very common during outpatient visits Documentation terminology Hyperglycemia High or elevated blood sugar Poorly controlled Inadequately controlled Out of control Uncontrolled clarify if hypo or hyperglycemia (ICD 10 CM Index) See also Coding Clinic, First Quarter 2016, p

8 Hypoglycemia (E11.64 ) Blood sugar < 70 mg/dl Coding requires some sort of intervention Symptoms unusual if > 50 mg/dl With or without coma (unexpected in outpatient setting) Documentation terminology Hypoglycemia Low blood sugar Uncontrolled? 15 Arthropathy (E11.61 ) Diabetic neuropathic arthropathy ( Charcot joint ) Chronic, progressive destruction of joint Due to absent sensation (sensory neuropathy) Repetitive, unrecognized joint injury Primarily foot and ankle Other types must be specified as diabetic Adhesive capsulitis (frozen shoulder) Painful, decrease in ROM without a known intrinsic shoulder disorder Calcific periarthritis (calcific tendinitis) Severe pain, sometimes with stiffness, occurring spontaneously usually in the morning X ray: periarticular calcifications Cause unclear 16

9 Circulatory Complications (E11.5 ) Peripheral vascular/artery disease (PVD/PAD) Atherosclerosis (arteriosclerosis) is the causative process Lower extremities only Upper extremities extremely unusual Not central arteries: coronary, carotid, aortic, renal, mesenteric With or without gangrene Coding Clinic, 2nd Quarter 2018, p. 7 Microangiopathy Damage to small vessel and capillary endothelium Contributes to retinopathy, neuropathy, nephropathy, atherosclerosis, ischemic ulcers 17 Hyperlipidemia Diabetic hyperlipidemia has unique characteristics: Hypertriglyceridemia Low HDL cholesterol LDL cholesterol not particularly elevated Clinical indicators: Triglycerides (fasting) > 200 mg/dl Severe > 500 mg/dl Sometimes several thousand mg/dl with lipemic (cloudy) serum HDL cholesterol < 40 mg/dl Coded E11.69 (other specified) + E78.5 (hyperlipidemia) Must be specified as diabetic 18

10 Hyperlipidemia Treatment to lower triglycerides: Low fat, diabetic diet; avoid alcohol Fibrates also increase HDL Gemfibrozil (Lopid) Fenofibrate (multiple brands) Niacin > 1,500 mg/day also increases HDL Omega 3 fatty acids (fish oil) 4 gm/day Occasionally statin drugs in very high doses for modest hypertriglyceridemia (not primarily for LDL cholesterol) Clinical validation Common documentation/coding error Most of the common forms of hyperlipidemia are associated with hypercholesterolemia (elevated LDLs) without significant hypertriglyceridemia Vast majority of diabetic patients with hyperlipidemia do not have diabetic hyperlipidemia 19 Kidney Complications (E11.2 ) Diabetic nephropathy Documentation terminology Nephropathy Kimmelstiel Wilson disease Intercapillary glomerulosclerosis Intracapillary glomerulonephrosis Specific diabetic renal diseases causing CKD stages 1 5 Chronic kidney disease (CKD) Include stage CKD stage GFR Stage 1* >90 Stage 2* Stage Stage 4 (CC) Stage 5 (CC) < 15 ESRD (MCC) N/A *Requires the presence of certain kidney damage markers (very common in diabetes) 20

11 Neuropathy (E11.4 ) Autonomic GI: gastroparesis, GERD, chronic diarrhea or constipation CV: orthostatic hypotension with or without syncope, resting tachycardia, exercise intolerance GU: bladder dysfunction, erectile dysfunction Sleep apnea Sensory motor peripheral neuropathy: Pain, numbness, loss of touch sensation, reflexes decreased or absent, muscle weakness if severe Mono = one limb or one nerve Poly = multiple nerves in multiple limbs Unspecified usually refers to polyneuropathy, but clarification not required Cranial mononeuropathy e.g., ocular muscles, Bell s palsy 21 Neuropathy (E11.4 ) Automatically linked terminology: Neuropathy Mononeuropathy Polyneuropathy Autonomic (poly) neuropathy Gastroparesis Neuralgia Amyotrophy 22

12 Oral Complications (E11.63 ) Periodontal disease (E11.630) Common diabetic complication Includes periodontitis and gingivitis Diabetic dry mouth: Common diabetic complication Often causes: multiple cavities, periodontal disease, and oral candidiasis Must be specified as diabetic Coded E (other oral complication NEC) + R68.2 (dry mouth) 23 Osteomyelitis (E11.69) Primarily caused by deep diabetic ulcer (hematogenous spread very unusual) Automatically linked (specifically listed without NEC in Index) Coded E11.69 (other specified complication) + a code from M86 (osteomyelitis) 24

13 Retinopathy (E11.4 ) Automatically linked: Retinopathy, unspecified Proliferative Nonproliferative Macular edema Cataract Ocular manifestation not directly related to retinopathy Diabetic glaucoma Ocular manifestation not directly related to retinopathy Must be specified as diabetic 25 Skin Complications (E11.62 ) Diabetic dermatitis (E11.620) Appears that a skin condition described as dermatitis is automatically linked to diabetes unless another cause is specified by the provider Not listed NEC by Index Many types of dermatitis have other specific causes, e.g., atopic and contact dermatitis are allergic in nature Consider clarification of dermatitis that is not clearly related to diabetes Necrobiosis lipoidica is automatically linked to diabetes Foot ulcer (E11.621) Use additional code to identify location Clarify if heel ulcer (usually non diabetic pressure ulcer but does suggest peripheral neuropathy) 26

14 Skin Complications (E11.62 ) Other non pressure ulcer (E11.622) Must be specified as diabetic Use additional code to identify location Clarify if appears to be pressure ulcer (e.g., heel), which suggests peripheral neuropathy Other diabetic skin complication NEC (E11.628) Must be specified as diabetic Use additional code for the specific complication Common diabetic skin complications: Granuloma annulare circular clusters of reddish/brown spots usually on hands and feet Diabetic dermopathy dull red papules that progress to small, round, atrophic hyperpigmented skin lesions usually on the shins Eruptive xanthomatosis due to severe hyperlipidemia; firm, yellow, pruritic bumps with surrounding red halos 27 Thank you. Questions? Richard Pinson RPinson@PinsonandTang.com In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 28