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Dial-In Instructions - HCPro · 2007. 1. 16. · 10:00 a.m.–11:30 a.m. (Pacific) A90-minute...
Transcript of Dial-In Instructions - HCPro · 2007. 1. 16. · 10:00 a.m.–11:30 a.m. (Pacific) A90-minute...
Conference name: Diabetes Coding: Understand the Disease and Its Documentation Requirements
Scheduled conference date: Wednesday, January 17, 2007
Scheduled conference time: 1:00 p.m.–2:30 p.m. (Eastern), 12:00 p.m.–1:30 p.m. (Central), 11:00 a.m.–12:30 p.m. (Mountain), 10:00 a.m.–11:30 a.m (Pacific)
Scheduled conference duration: 90 minutes
PLEASE NOTE: If the audioconference occurs March through November, the time reflects daylight savings. Ifyour area does NOT observe daylight savings, times will be one hour earlier.
Your registration entitles you to ONE telephone connection to the audioconference. Invite as many people as youwish to listen to the audioconference on your speakerphone. Permission is given to make copies of the written
materials for anyone who is listening.
In order to avoid delays in connecting to the conference, we recommendthat you dial into the audioconference 15 minutes prior to the start time.
Dial-in instructions1. Dial 877/407-2989 and follow the voice prompts.2. You will be greeted by an operator.3. Give the operator the pass code, 011707, and the last name of the person who registered for the audioconference.4. The operator will verify the name of your facility.5. You will then be placed into the conference.
Technical difficulties1. If you experience any difficulties with the dial-in process, please call the conference center reservation line at
877/407-7177.2. If you need technical assistance during the audio portion of the program, please press the star (*) key, followed by
the 0 key, on your touch-tone phone, and an operator will assist you. If you are disconnected during the conference, dial 877/407-2989.
Q&A session1. To enter the questioning queue during the Q&A session, callers need to push the star (*) key, followed by the 1 key,
on their touch-tone phones. Note: For most programs, the Q&A portion of the program generally falls after the first hour of presentation. Please do not try to enter the queue before this portion of the program.
2. If you prefer not to ask your questions on the air, you can fax your questions to 877/808-1533 or 201/612-8027.However, note that you can only fax your questions during the program.
Prior to the programYou can also send your questions via e-mail to [email protected]. The deadline to send presubmitted questions via e-mail is 01/16/07 @ 5:30 PM Eastern. Please note that it is likely that not all questions will be answered.
Program evaluation survey In this materials packet on page 2, we have included a program evaluation letter that has the URL link to our program sur-vey. We would appreciate it if you could go to the link provided and complete the survey when you return to your office.
Continuing education documentation If CEs are offered with this program, a separate link containing important information will be provided along with the pro-gram materials. Please follow the instructions in the CE documentation.
Dial-In Instructions
200 Hoods Lane PO Box 1168 Marblehead MA 01945 TEL 781 639 1872 FAX 781 639 7857 URL www.hcpro.com
Program Evaluation
Dear Program Participant,
Thank you for attending the HCPro program today. We hope you found it to be informative andhelpful.
To ensure a positive experience for our customers and to deliver the best possible products andservices, we would like your feedback. Because your time is valuable, we have limited the evalua-tion to some brief questions found at the link below:
http://www.zoomerang.com/survey.zgi?p=WEB225YTDJ65RN
We would also ask that you forward the link to others in your facility who attended the program fortheir input as well. To ensure that your completed form receives our attention, please return to uswithin six days from the date of this program.
If you enjoyed this program, you may purchase a tape or CD at the special attendee price of just$70. Simply call our customer service team at 800/650-6787, and mention your source code:SURVEYAD. Keep the tape or CD handy, and listen again at your convenience—whenever you oryour staff might benefit from a refresher, or when your new employees are ready for training.
We appreciate your time and suggestions. We hope that you will continue to rely on HCPro pro-grams as an important resource for pertinent and timely information.
Sincerely,
Frank MorelloDirector of MultimediaHCPro, Inc.
Diabetes Coding: Understand thedisease and its documentation
requirements
1:00 p.m.–2:30 p.m. (Eastern)
12:00 p.m.–1:30 p.m. (Central)
11:00 a.m.–12:30 p.m. (Mountain)
10:00 a.m.–11:30 a.m. (Pacific)
A 90-minute interactive audioconference
Wednesday, January 17, 2007
ii Diabetes Coding: Understand the disease and its documentation requirements
In our materials, we strive to provide our audience with useful and timely information. The live audioconfer-ence will follow the enclosed agenda. Occasionally, our speakers will refer to the enclosed materials. Wehave noticed that non-HCPro audioconference materials often follow the speakers’ presentations bullet-by-bullet and page-by-page. However, because our presentations are less rigid and rely more on speaker inter-action, we do not include each speaker’s entire presentation. The enclosed materials contain helpful forms,crosswalks, policies, charts, and graphs. We hope that you will find this information useful in the future.
HCPro, Inc., is not affiliated in any way with The Joint Commission on Accreditation of HealthcareOrganizations, which owns the The Joint Commission trademark.
iiiDiabetes Coding: Understand the disease and its documentation requirements
The “Diabetes Coding: Understand the Disease and Its Documentation Requirements” audioconferencematerials package is published by HCPro, Inc., 200 Hoods Lane, P.O. Box 1168, Marblehead, MA 01945.
Copyright 2007, HCPro, Inc.
Attendance at the audioconference is restricted to employees, consultants, and members of the medical staffof the Licensee.
The audioconference materials are intended solely for use in conjunction with the associated HCPro audio-conference. The Licensee may make copies of these materials for internal use by attendees of the audio-conference only. All such copies must bear the following legend: Dissemination of any information in thesematerials or the audioconference to any party other than the Licensee or its employees is strictly prohibited.
Advice given is general, and attendees and readers of the materials should consult professional counsel forspecific legal, ethical, or clinical questions. HCPro, Inc., is not affiliated in any way with the Joint Commissionon Accreditation of Healthcare Organizations, which owns the JCAHO trademark.
For more information, please contact:
HCPro, Inc. 200 Hoods LaneP.O. Box 1168Marblehead, MA 01945Phone: 800/650-6787Fax: 781/639-0179E-mail: [email protected] site: www.hcpro.com
iv Diabetes Coding: Understand the disease and its documentation requirements
Dear Colleague,
Thank you for participating in our “Diabetes Coding: Understand theDisease and Its Documentation Requirements” audioconference withRobert S. Gold, MD, and Shannon McCall, RHIA, CCS, CPC, moderat-ed by Lisa Eramo. We are excited about the opportunity to interact withyou directly and encourage you to ask our experts your questions duringthe audioconference. If you would like to submit a question before theaudioconference, please send it to [email protected] and provide theprogram date in the subject line. We cannot guarantee that your questionwill be answered during the program, but we will do our best to take agood cross section of questions.
If at any time you have comments, suggestions, or ideas about how wecan improve our audioconference, or if you have any questions about theaudio-conference itself, please do not hesitate to contact me. And if youwould like any additional information about our other products and serv-ices, please contact our Customer Service Department at 800/650-6787.
We have enclosed an evaluation along with the audioconference materi-als. After the audioconference, please take a minute to complete the eval-uation to let us know what you think. We value your opinion.
Thanks again for working with us.
Best regards,
Wendy WalshAssociate ProducerFax: 781/639-7857E-mail: [email protected]
200 Hoods Lane
P.O. Box 1168
Marblehead, MA 01945
Tel: 800/650-6787
Fax: 800/639-8511
vDiabetes Coding: Understand the disease and its documentation requirements
Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi
Speaker profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Exhibit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Presentation by Robert S. Gold, MD, and Shannon McCall, RHIA, CCS, CPC
Exhibit B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Link to the report of the Expert Committee on the Diagnosis and Classification of DiabetesMellitus and a table of Etiologic Classifications of Diabetes Mellitus
Exhibit C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Quizlet: ICD-9 Coding for Diabetes Mellitus
Exhibit D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25List of HIM “Acronyms to Know”
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Contents
vi Diabetes Coding: Understand the disease and its documentation requirements
Agenda
I. Diseases caused by diabetes versus diseases in diabetics: How to differentiate and correctly code for them
A. Reporting combination codes with manifestation codesB. Coding each individually
II. The basics of the clinical classification of all forms of diabetes and the impact on coding
A Type I diabeticB. Type II v. Type I
III. Diabetes uncontrolled and poorly controlledA. Fifth digit assignmentsB. Reporting the additional code V58.67C. Factoring “poorly controlled” or “poor control” in code assignment
when they are documented in the medical record
IV. The current status of diabetes from a coding standpoint and the future for 2008
V. Physician queries: How to get the info you need from the medical staff
VI. Selected case studies
VII. Live Q&A
viiDiabetes Coding: Understand the disease and its documentation requirements
Speaker profiles
Robert S. Gold, MD
Robert S. Gold, MD, is founder and CEO of DCBA, Inc., in Atlanta, GA, a consultingfirm that provides physician-to-physician educational programs in clinical documentationimprovement, including training staffs to perform concurrent review, and HIM profes-sionals to understand the clinical aspects of diseases and procedures to which theyassign codes. He has more than 40 years of experience as a physician, medical direc-tor, and consultant. Gold writes Clinically Speaking for Briefings on Coding
Compliance Strategies and Minute for the Medical Staff for Medical Records Briefing, and is the author ofthe new training handbook, Documentation Strategies to Support Severity of Illness: Ensure an accurate pro-fessional profile, all from HCPro.
Shannon McCall, RHIA, CCS, CPC
Shannon McCall, RHIA, CCS, CPC, is director of coding and HIM at HCPro, Inc.,where she serves as the lead instructor for two of the Certified Coder Boot Camps®,which cover physician and outpatient hospital coding and inpatient hospital facility cod-ing. As a member of HCPro, Inc.’s consulting staff, she works with hospitals, medicalpractices, and other healthcare providers on a wide range of coding-related issues witha particular focus on coding reviews and audits. McCall has extensive experience with
coding for both physician and hospital services. Prior to joining HCPro, Inc., she worked for Per-SeTechnologies, a national medical practice management company, where her duties included serving asinstructor for Per-Se’s in-house coding training and certification program.
Exhibit A
Presentation by Robert S. Gold, MD, and Shannon McCall, RHIA, CCS, CPC
EXHIBIT A
2 Diabetes Coding: Understand the disease and its documentation requirements
1
Diabetes Coding:
Understand the Disease and its
Documentation Requirements
� Shannon E. McCall, RHIA, CCS, CPC
Director of Coding and HIM
HCPro, Inc.
Marblehead, MA
� Robert S. Gold, MD
CEO
DCBA, Inc.
Atlanta, GA
2
Agenda and Approach
� The clinical differences between Type I and Type II
diabetes—and all of the other kinds of diabetes
� The rules and assigning of correct codes to the highest
degree of specificity
� Coding and documentation traps coders sometimes fall
into
� Proposed code expansions related to diabetes in
preparation for ICD-10 and involvement of the medical
staff
� Physician documentation pitfalls and best coding needs
� How to engage physicians for more information to
avoid making assumptions based on the documentation
3Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT A
3
Goals and Objectives
� At the end of the audioconference, you (participants)
will be able to:
� Illustrate the clinical differences between diseases caused by
diabetes versus diseases in diabetics and how to correctly
code them
� Identify the basics of the clinical classification of all forms of
diabetes and the impact on coding
� Explain uncontrolled v. poorly controlled diabetes and the
appropriate coding assignments based on documentation in
the medical record
� Summarize current coding guidelines and what is expected
for 2008
� Understand how to query a physician using information
obtained in the medical record to assign the most specific
diabetic codes
4
Definitions and Determinations
� Diabetes [Mid-16th century. Via Latin < Greek, "passer
through, siphon" < diabainein "go through"]—a disease
whereby the patient produces an excess amount of urine
� Mellitus—sweet, as honey—causes fruity odor to
breath when Type I diabetic is in ketoacidosis (ONLY
Type I patients develop true ketoacidosis!)
� Insipidus—bland—due to posterior pituitary tumor that
produces large amounts of urine through lack of ADH
(antidiuretic hormone) whose job it is to conserve water
(central diabetes insipidus) or lack of reaction by the
kidneys (nephrogenic diabetes insipidus)
EXHIBIT A
4 Diabetes Coding: Understand the disease and its documentation requirements
5
“Poly” Want a Diagnosis?
� Poly uria—excessive
urination
� Poly dipsia—excessive
thirst
� Poly phagia—excessive
hunger
6
Diabetes
� Juvenile (IDDM) –Type Idiabetes occurs in a state ofinsulin deficiency resultingfrom pancreatic beta celldestruction
� Adult (NIDDM)—Type IIdiabetes results fromincreased resistance to theeffects of insulin. Thesepatients may require insulinfor control.
5Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT A
7
Coding Type I vs. Type II Diabetes
� Category 250.xx
� Fourth digit is based on
accompanying
manifestations/complications
� Fifth Digit is based on the “Type”
of Diabetes and the nature of the
diabetes (not stated as
uncontrolled and uncontrolled)
• Per the official guidelines, “if the
type of diabetes mellitus is not
documented in the medical record
the default is type II.”
8
Coding Type I vs. Type II Diabetes
� Use of acronym “IDDM” and
“NIDDM”
� In 2005, the acronym was removed
from the 5th digit description in the
ICD-9-CM Manual
� A physician must document that the
patient is a Type I diabetic to utilize
a 5th digit of 1 or 3.
• Per the AHA’s Coding Clinic 2Q
2004, the administration of insulin
has no effect on code assignment.
Only the type of diabetes (I or II)
affects code assignment. Assign
fifth digit “0” if the type is
unspecified in the diagnosis and
additional information as to type is
not available.
EXHIBIT A
6 Diabetes Coding: Understand the disease and its documentation requirements
9
Coding Type I vs. Type II Diabetes
� Use of V58.67 as an additionalcode
� Code V58.67 should beassigned when a patient ismaintained on insulin for TypeII diabetes mellitus.
� Code V58.67 should not beassigned if insulin is giventemporarily to bring a type IIpatient’s blood sugar undercontrol during an encounter.
� It is not necessary to reportV58.67 when a patient has typeI diabetes mellitus since it isimplied that the patient is oninsulin (via pump or injection).
10
Diabetes Terminology
� Is it Type I or Type II?
� Type II on insulin option
� Is it some other etiology?
� Is it controlled or uncontrolled?
� HbA1C
� Is it related to other problems?
� Gastroparesis? Retinopathy? Renal failure? Peripheral
neuropathy? Etc.
7Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT A
11
Etiologic Classification of Diabetes
� Type I diabetes—beta cell destruction, usually leading
to absolute insulin deficiency
� Type II diabetes—insulin resistance or deficiency plus
resistance
12
Coding Uncontrolled vs. Poorly
Controlled Diabetes
� Fifth-digits for Category 250
� 0- Type II, or unspecified type, not stated as uncontrolled
� 1- Type I, not stated as uncontrolled
� 2- Type II, or unspecified type, uncontrolled
� 3- Type I, uncontrolled
• “Poorly controlled” is a non-essential modifier and does not
affect fifth-digit assignment
– Query the physician to determine whether “poorly controlled” and
“poor control” is indicative of uncontrolled blood glucose levels for
this patient.
EXHIBIT A
8 Diabetes Coding: Understand the disease and its documentation requirements
13
Etiologic Classification of Diabetes
� Other specific types (Secondary causes of Diabetes)
� Genetic defects of beta cell function
� Genetic defects in insulin action
• Type A insulin resistance
• Leprechaunism
• Rabson Mendenhall syndrome
• Lipoatrophic diabetes
14
More Diabetes
� Diseases of the exocrine pancreas
• Pancreatitis
• Trauma/pancreatectomy
• Neoplasia
• Cystic fibrosis
• Hemachromatosis
• Fibrocalculous pancreas
� Endocrinopathies
• Acromegaly
• Cushing’s syndrome
• Glucagonoma
• Hyperthyroidism
• Somatostatinoma
• Aldosteronoma
9Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT A
15
Even More Diabetes
� Drug or chemical induced
• Vacor
• Pentamidine
• Nicotinic acid
• Steroids (glucocorticoids)
• Thyroid hormone
• Beta agonists
• Thiazides
• Dilantin
• Alpha interferon
� Infections
• Congenital rubella
• Cytomegalovirus
� Uncommon immune-mediated diabetes
• “Stiff man” syndrome
• Anti-insulin receptor antibodies
16
Son of Diabetes
� Other genetic syndromes
• Down’s syndrome (758.0)
• Klinefelter’s syndrome (758.7)
• Turner’s syndrome (758.6)
• Wolfram’s syndrome (253.5, 250.xx, 377.10, 389.xx))
– A syndrome comprising diabetes insipidus, a mild form of diabetesmellitus, optic atrophy, and deafness. It is an autosomal recessiveinherited disorder, with the chromosomal abnormality on the shortarm of chromosome. Also called DIDMOAD, for diabetesinsipidus, diabetes mellitus, optic atrophy and deafness
• Friedrich’s ataxia (334.0)
• Huntington’s chorea (333.4)
• Porphyria (277.1)
• Lawrence Moon Biedl syndrome (759.89)
� Myotonic dystrophy (359.2)
� Prader Willi syndrome (759.81)
� Gestational Diabetes
EXHIBIT A
10 Diabetes Coding: Understand the disease and its documentation requirements
17
Other Diabetes Considerations
� Diabetes insipidus
� Not diabetes mellitus at all
� Related to posterior pituitary malfunction (central) or renalresponse to ADH (nephrogenic)
� Characterized by excess thirst (drinking) and excess urineproduction—same as two of three DM characteristics
� Type 1 � Diabetes
� Recent discussions of a patient with SOME decrease ininsulin production (like Type I) who develops early non-responsiveness to that insulin (like Type II), neither of whichwould have become manifest alone
� Type 3 Diabetes
� Even newer classification—not even confirmed toexist—related to sugar metabolism in the brain
� Not a recognized term by ADA
18
Coding “Other” Diabetes
� Drug or chemical induced (e.g., steroids)
� ICD-9-CM code 251.8, Other specified disorders of
pancreatic internal secretion
• Per the AHA Coding Clinic 2Q 1998, it is inappropriate to use
a code from category 250 for “secondary” diabetes mellitus.
� Gestational diabetes
� ICD-9-CM code 648.8x, Abnormal glucose tolerance
• Use additional code V58.67, if applicable
• Do not report in addition to codes 790.2x or 250.xx
� Diabetes insipidus
� ICD-9-CM code 253.5
� Type 1 � and 3
� Currently, there are no ICD-9-CM codes for these
classifications
11Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT A
19
Anatomy of Pancreas
Duodenum12
Tail of pancreas11
Omental tuber10
Inferior margin9
Anterior margin8
Superior margin7
Inferior surface6
Anterior surface5
Body of pancreas4
Pancreatic notch3
Uncinate process2
Head of pancreas1
http://training.seer.cancer.gov/ss_module13_biliary_tract/unit02_sec01_anatomy.html
20
Periampullary Anatomy
http://digestive.niddk.nih.gov/ddiseases/pubs/gallstones/index.htm
EXHIBIT A
12 Diabetes Coding: Understand the disease and its documentation requirements
21
Functional Components of Pancreas
� Exocrine
� Digestive enzymes
� Acinar glands
� Ducts
� Endocrine
� Glands of Islet cells
• Beta cells insulin
• Alpha cells glucagon
• Delta cells somatostatin
� No ducts
http://www.fda.gov/cber/genetherapy/pancislet.htm
Somatostatin inhibits parietal
cells, gastrin stimulates them
Insulin drops blood sugar,
glucagon raises it
22
Problems with Pancreas
� Malfunction
� Tumors
�Exocrine tumors
�Endocrine tumors—gastrinoma, glucagonoma, insulinoma
� Zollinger-Ellison (ZE) Syndrome—gastrinoma
� Inflammation—pancreatitis
�Alcohol
�Gallstone
�Viral
� Trauma
� Posterior penetrating ulcers
� Splenic artery aneurysm
13Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT A
23
Distant Manifestations of Diabetes
� Vascular disease—3 of 4 diabetes deaths from heart andperipheral vascular disease
� Peripheral vessels including carotids
� Heart vessels
� Triopathy—no code for all three—must name them
� Neuropathy
• Autonomic neuropathy—often presents as syncope
• Gastroparesis
• Sensory loss—leads to Charcot Foot and Diabetic footulcers
� Retinopathy—two types
• Proliferative—too many blood vessels trying to heal retina
• Non-proliferative—not enough blood flow due to death ofretina
� Nephropathy—leads to CKD
� Also have dermopathy
24
What Vessels are Involved?� Starts in heart
� Aorta
� Major arteries (brachiocephalic,
carotid, subclavian, renals, mesenterics,
common iliacs)
� Next level major vessels (axillary,
colics, femorals, etc.)
� And so on and so on and so on to
radial, ulnar, dorsalis pedis, etc.
� Finally to precapillaries and capillaries
� Diabetes vascular changes are
microvascular disease
� A bypass is done for atherosclerotic
disease of major blood vessels—it may
help heal diabetic microvascular
problems by increasing inflowhttp://diabetes.niddk.nih.gov/dm/pubs/stroke/
EXHIBIT A
14 Diabetes Coding: Understand the disease and its documentation requirements
25
Risk of Atherosclerosis Increased
� Diabetic patients develop
atherosclerosis more
rapidly than non-diabetics
� Major vessel occlusion is
still atherosclerosis in a
diabetic
� Risk of heart attack, stroke
doubled in diabetics
� Risk of second event
higher than non-diabetics
and higher potential for
mortalityhttp://www.nhlbi.nih.gov/health/dci/Diseases/Athero
sclerosis/Atherosclerosis_WhatIs.html
26
What Bypasses Do You See?
�Aorto-iliac
�Aorto-bifemoral
�Aorto-femoral, fem-fem
�Femoropopliteal bypass
�Femoro-anterior tibial bypass
�Aorto-mesenteric
�Aorto-renal
All for atherosclerotic occlusive disease. Patient may havenon-healing diabetic foot ulcer, but is non-healing becauseof inoperable microvascular disease or inadequate inflow.
Options: Angioplasty and stent, endarterectomy—youdon’t remove sugar!
15Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT A
27
Diabetic Foot Ulcer? Query!
� There are three primary types of ulcerations of the lower extremity
that will require referral to the Vascular Surgery Service.
� Type 1: Ulceration of the distal extremity, typically the toes, due to
arterial insufficiency. These can be painful and despite good local
wound care fail to heal due to a lack of adequate blood supply.
Treatment involves careful wound management and improvement of
blood flow to the extremity, which often requires operative
intervention.
� Type 2: Ulceration due to a neurotrophic ulcer in diabetics. This
type is typically over bony prominences and is generally painless
unless it is also infected. Treatment includes alleviation of any
weight-bearing on this pressure area, controlling infection and
assuring adequate blood flow.
� Type 3: Ulceration in the lower extremities is due to venous
insufficiency. Management goals are proper support of the lower
extremities with some type of compression dressing as well as
controlling infection.
http://www.mamc.amedd.army.mil/referral/guidelines/derm_extremityulcer.htm
28
Retinopathy
� Complication of diabeticmicrovascular changes
� Leads to ischemia ofretina
� Ischemia can lead tocompensatoryproliferation of bloodvessels or death of tissue
� Nonproliferativeretinopathy
� Proliferativeretinopathy—this iswhat laser treatment isfor—to cauterizeproliferating vessels thatblock light from hittingretina
http://nihseniorhealth.gov/diabeticretinopathy/
whatisdiabeticretinopathy/eye_popup.html
EXHIBIT A
16 Diabetes Coding: Understand the disease and its documentation requirements
29
Nephropathy
� Decrease in GFR over time,
progression to ESRD
� May be called Kimmelstein-
Wilson Disease or diabetic
glomerulosclerosis
� Thickening of glomerulus—protein
loss—microalbuminuria
� Loss of glomeruli through microvascular ischemic
change
� Progression until gross albuminuria and hypertension
which results FROM THE DIABETIC VASCULAR
CHANGES
http://bicmra.usuhs.mil
30
Coding Diabetic Manifestations
� Fourth-digits for Category 250.xx
� Identify the absence or presence of
complications/manifestations
• 250.1x-250.3x- Complications
– E.g., Ketoacidosis
• 250.4x-250.8x- Manifestations
– Renal (e.g., nephropathy)
– Ophthalmic (e.g., retinopathy)
– Neurological (e.g., gastroparesis)
– Peripheral circulatory disorders (e.g., gangrene)
– Other (e.g., ulcerations)
» Use additional code to identify the specific manifestations
17Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT A
31
Coding Diabetic Manifestations
� Are these conditions inherently assumed to be
diabetic related if listed with a diagnosis of
diabetes mellitus?
�NO!!!
• Per the AHA Coding Clinic, 1Q, 2004, Conditionslisted with a diagnosis of diabetes mellitus or in adiabetic patient are not necessarily complications ofthe diabetes. The condition should be coded as suchonly when the physician identifies it as a diabeticcomplication.
32
Functional Anatomy of Kidney
http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/yourkidneys.pdf
Erythropoietin is
produced by
peritubular
capillary
endothelium
EXHIBIT A
18 Diabetes Coding: Understand the disease and its documentation requirements
33
Proposed Additional Codes for 2008
� New category 249 Diabetes mellitus due to underlyingcondition� Diabetes due to adverse effect of drug
� Diabetes mellitus due to late effect of adverse effect of drug,disease, and poisoning
� Secondary diabetes mellitus
� Code first underlying condition, such as:� Cushing’s syndrome (255.0)
� Cystic fibrosis (277.00-277.09)
� Malignant neoplasm of pancreas (157.0-157.9)
� Poisoning—see table of drugs and chemicals
� Use additional code to identify:� Adverse effect of drug—see table of drugs and chemicals
� Any associated insulin use (V58.67)
� Late effect of adverse effect of drug, poisoning and trauma909.5, 909.0, 908.1)
� Personal history of pancreatitis (V12.79)
34
Proposed Additional Codes
� New code 249.0 Diabetes mellitus due to underlying
condition without mention of complication
� New code 249.1 Diabetes mellitus due to underlying
condition with ketoacidosis
� New code 249.2 Diabetes mellitus due to underlying
condition with hyperosmolarity
� New code 249.3 Diabetes mellitus due to underlying
condition with other coma
� New code 249.4 Diabetes mellitus due to underlying
condition with renal manifestations
� New code 249.5 Diabetes mellitus due to underlying
condition with ophthalmic manifestations
19Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT A
35
� New code 249.6 Diabetes mellitus due to underlying
condition with neurological manifestations
� New code 249.7 Diabetes mellitus due to underlying
condition with peripheral circulatory disorders
� New code 249.8 Diabetes mellitus due to underlying
condition with other specified manifestations
� New code 249.9 Diabetes mellitus due to underlying
condition with unspecified complication
Proposed Additional Codes
Exhibit B
Link to the report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitusand a table of Etiologic Classifications of Diabetes Mellitus
Source: Robert S. Gold, MD
21Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT B
LINK to Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus
http://care.diabetesjournals.org/cgi/content/full/26/suppl_1/s5
������������
TABLE 1Etiologic Classifications of Diabetes Mellitus
Type 1 diabetes mellitus*
Type 2 diabetes mellitus*
Other specific types:
Genetic defects of beta-cell functionGenetic defects in insulin actionDiseases of the exocrine pancreas
PancreatitisTrauma/pancreatectomyNeoplasiaCystic fibrosisHemochromatosisOthers
EndocrinopathiesAcromegalyCushing's syndromeGlucagonomaPheochromocytomaHyperthyroidismSomatostatinomaAldosteronomaOthers
Drug- or chemical-inducedVacor†PentamidineNicotinic acidGlucocorticoidsThyroid hormoneDiazoxideBeta-adrenergic agonistsThiazidesPhenytoinAlfa-interferonOthers
InfectionsCongenital rubellaCytomegalovirusOthers
Uncommon forms of immune- mediated diabetesOther genetic syndromes sometimes associatedwith diabetes
Down syndromeKlinefelter's syndromeTurner's syndromeWolfram syndromeFriedreich's ataxiaHuntington's choreaLawrence-Moon Beidel syndromeMyotonic dystrophyPorphyriaPrader-Willi syndromeOthers
Gestational diabetes mellitus
*--Patients with any form of diabetes may require insulin treatment at some stage of the disease. Use of
insulin does not, of itself, classify the patient.
†--Vacor is an acute rodenticide that was released in 1975 but withdrawn as a general-use pesticide in 1979
because of severe toxicity. Exposure produces destruction of the beta cells of the pancreas, causing diabetes
mellitus in survivors.
Exhibit C
Quizlet: ICD-9 Coding for Diabetes Mellitus
Source: HCPro, Inc.
23Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT C
Quizlet: ICD-9 Coding for Diabetes Mellitus
1. A patient who is 10 years old is diagnosed with diabetes mellitus. The physician
does not specify whether the patient is a Type I or Type II diabetic. The patient
has no associated manifestations or complications. What is the correct code?
a. 250.01
b. 250.00
c. 790.29
d. 250.02
2. A patient with Type II diabetes that is normally controlled on Glucophage is
temporarily placed on sliding scale insulin to stabilize his glucose levels. The
patient has no associated manifestations or complications. What is the correct
code(s)?
a. 250.00, V58.67
b. 250.01
c. 250.01, V58.67
d. 250.00
3. A patient presents to an ophthalmologist’s office for treatment of diabetic
cataracts. The patient is a Type I diabetic. What is the correct code(s)?
a. 366.9, 250.01
b. 250.51, 366.41
c. 366.41, 250.51
d. 250.01, 366.41
4. A patient presents to an emergency room in a diabetic hypoglycemic coma (not
hyperosmolar) due to the failure of her insulin pump. The patient is a Type I
diabetic. What are the appropriate code(s)?
a. 996.57, 962.3, 250.31, E932.3
b. 996.57, 962.3, 250.33, E932.3
c. 996.57, 250.31, E932.3
d. 251.0, 250.01, 996.57, 962.3, E933.3
5. A patient is documented as having diabetes mellitus in a medical record. Patient
medication administration record states he is are on Humulin 70/30. There is no
further documentation to specify the type of diabetes. What is the appropriate
code(s)?
a. 250.00
b. 250.01
c. 250.00, V58.67
d. 250.01, V58.67
EXHIBIT C
24 Diabetes Coding: Understand the disease and its documentation requirements
Quizlet: ICD-9 Coding for Diabetes Mellitus
ANSWERS
1. = b. 250.00
2. = d. 250.00
3. = b. 250.51, 366.41
4. = c. 996.57, 250.31, E932.3
5. = a. 250.00
Exhibit D
List of HIM “Acronyms to Know”
Source: HCPro, Inc.
EXHIBIT D
26 Diabetes Coding: Understand the disease and its documentation requirements- 1 -
HIM Acronyms to Know
AAPC American Academy of Professional Coders
AHA American Hospital Association
AHIC American Health Information Community
AHIMA American Health Information Management Association
AHRQ Agency for Health Care Research and Quality
AMI Acute myocardial infarction
AOA American Osteopathic Association
APCs Ambulatory payment classifications
APR DRG All Patient Refined Diagnosis Related Group System
ASC Ambulatory surgical center
ASP Average sales price
AWP Average wholesale price
BBA Balanced Budget Act of 1997, Pub. L. 105-33BLS Bureau of Labor Statistics
CAH Critical access hospital
CART CMS Abstraction & Reporting Tool
CBSAs Core-based statistical areas
CC Complication or comorbidity
CCHIT Certification Commission for Health Information Technology
CCR Continuity of care record/Cost to charge ratio
CDAC Clinical Data Abstraction Center
CDM Charge description master
CPI Consumer price index
CMI Case-mix index
CMS Centers for Medicare & Medicaid Services
CMSA Consolidated Metropolitan Statistical Area
COBRA Consolidated Omnibus Reconciliation Act of 1985, Pub. L. 99-272
CPI Consumer price index
CPT Current Procedural Terminology
CRNA Certified registered nurse anesthetist
CT Computed tomography
CY Calendar year
DED Dedicated emergency department
DRA Deficit Reduction Act of 2005, Pub. L. 109-171
DRG Diagnosis-related group
DSH Disproportionate share hospital
ECI Employment cost index
ED Emergency department
EHR Electronic health record
EMR Electronic medical record
27Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT D
- 2 -
EMTALA Emergency Medical Treatment and Labor Act of 1986, Pub. L. 99-272
EOB Explanation of benefits
FDA Food and Drug Administration
FFY Federal fiscal year
FI Fiscal intermediary
FQHC Federally qualified health center
FY Fiscal year
GAAP Generally Accepted Accounting Principles
GAF Geographic Adjustment Factor
GME Graduate medical education
HCFA Health Care Financing Administration
HCPCS Healthcare Common Procedure Coding System
HCRIS Hospital Cost Report Information System
HHA Home health agency
HHS Department of Health and Human Services
HIC Health insurance card
HIMSS Health Information Management Systems Society
HIPAA Health Insurance Portability and Accountability Act of 1996
HIS Health information system/services
HIT Health information technology
HMO Health maintenance organization
HSA Health savings account
HSRVcc Hospital-specific relative value cost center
HQA Hospital Quality Alliance
HQI Hospital Quality Initiative
HwH Hospital-within-a-hospital
ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification
ICD-10-PCS International Classification of Diseases, Tenth Edition Procedure Coding System
ICU Intensive care unit
IHS Indian Health Service
IME Indirect medical education
IOM Institute of Medicine
IPF Inpatient psychiatric facility
IPPS Acute care hospital inpatient prospective payment system
IRF Inpatient rehabilitation facility
IT Information technology
JCAHO Joint Commission on Accreditation of Healthcare Organizations
LCD Local coverage determination
LTC-DRG Long-term care diagnosis-related group
LTCH Long-term care hospital
EXHIBIT D
28 Diabetes Coding: Understand the disease and its documentation requirements- 3 -
MAC Medicare administrative contractor
MCE Medicare Code Editor
MCO Managed care organization
MCV Major cardiovascular condition
MDC Major diagnostic category
MDH Medicare-dependent, small rural hospital
MedPAC Medicare Payment Advisory Commission
MedPAR Medicare Provider Analysis and Review File
MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L.
108-173
MRHFP Medicare Rural Hospital Flexibility Program
NAHIT National Alliance for Health Information Technology
NCCI National Correct Coding Initiative
NCD National coverage determination
NCHS National Center for Health Statistics
NCQA National Committee for Quality Assurance
NCVHS National Committee on Vital and Health Statistics
NHIN National health information network
NICU Neonatal intensive care unit
NPI National provider identifier
NQF National Quality Forum
NVHRI National Voluntary Hospital Reporting Initiative
OCE Outpatient code editor
OCR Office for Civil Rights
OES Occupational employment statistics
OIG Office of the Inspector General
OMB Executive Office of Management and Budget
OPPS Outpatient prospective payment system
OR Operating room
OSCAR Online Survey Certification and Reporting (System)
PPI Producer price index
PPS Prospective payment system
PRA Per resident amount
ProPAC Prospective Payment Assessment Commission
PRM Provider Reimbursement Manual
PRRB Provider Reimbursement Review Board
PS&R Provider Statistical and Reimbursement (System)
QIG Quality Improvement Group, CMS
QIO Quality Improvement Organization
29Diabetes Coding: Understand the disease and its documentation requirements
EXHIBIT D
- 4 -
RA Remittance advice
RC Revenue code
RHC Rural health clinic
RHIO Regional health information organization
RHQDAPU Reporting hospital quality data for annual payment update
RRC Rural referral center
RY Rate year
SAF Standard Analytic File
SCH Sole community hospital
SNF Skilled nursing facility
SOCs Standard occupational classifications
SSA Social Security Administration
SSI Supplemental Security Income
ST Status indicator
TAG Technical Advisory Group
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248
UHDDS Uniform hospital discharge data set
Resources
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RESOURCES
32 Diabetes Coding: Understand the Disease and Its Documentation Requirements
HCPro sites
HCPro: www.hcpro.comHCPro's mission is to meet the specialized information, advisory, and education needs of the healthcareindustry and to learn from and respond to our customers with services that meet or exceed the quality thatthey expect. Visit HCPro's Web site at www.hcpro.com to take advantage of our new Internet resources.
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33Diabetes Coding: Understand the Disease and Its Documentation Requirements
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