Pediatrics: Look for These Big ICD-10 Changes for Diabetes Coding

Under ICD-10, you’ll say goodbye to the ‘250.x’ series.

As a lot of pediatric coders already know, once a patient presents with diabetes, you should decide the fourth digit for ICD-9 code 250.xx (Diabetes mellitus) as per the type of diabetic complication the patient has, if there is any. In case the patient presents with diabetes without any complications, your first four digits will essentially be 250.0 (Diabetes mellitus without mention of complication).

In ICD-9 code, the fifth digit offers the final two pieces of info on the patient’s diabetic condition: the diabetes type (I or II) and whether it is controlled.

ICD-10 Change: While your diagnosis coding system changes, you’ll no longer turn to the same code section for both Type 1 and Type 2 diabetes. Even though you are presently used to to starting off with "250" for all diabetes patients, your coding choices will expand dramatically under ICD-10.

Type 1: You’ll code all Type 1 patients by starting out with the E10 series (Type 1 diabetes mellitus), and after that you’ll move on from there after studying the patient’s chart to decide whether any further manifestations exist.

Medical Billing and Coding Example: A seven-year-old patient comes with Type 1 diabetes and is in ketoacidosis, however is not in a coma. In this scenario, you’ll look to E10 as your first three characters to reflect the Type 1 diagnosis, and then the additional digits "10" to reflect that the patient is in ketoacidosis without a coma. Consequently, the full code will essentially be E10.10 (Type 1 diabetes mellitus with ketoacidosis without coma).

Type 2: You’ll code all Type 2 patients by starting out with the E11 series (Type 2 diabetes mellitus), then moving on from there after studying the patient’s chart to decide whether any further manifestations exist.

Medical Billing and Coding example: You see a 17-year-old obese patient with Type 2 diabetes and hyperosmolarity, however who is not in a coma. In this scenario, you’ll go straight to E11.x and scroll down to E11.00 (Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic hyperosmolar coma [NKHHC]).

Documentation: Only because Type I diabetes consists of the phrase "juvenile onset" in parentheses following the descriptor, don’t assume that all pediatric patients have Type I diabetes. It is becoming even more common for pediatricians to treat Type II diabetes that is developed in childhood or adolescence.

Helpful in deciding whether a patient has Type I or Type II diabetes is the results of a C-peptide assay, which measures insulin production and can specify which type of diabetes is present. These test results may be significant as you select your fifth digit, so you must check the medical billing and coding documentation for those results.

Think All ICD-9 Codes Expand Into Multiple Options? Think Again.

Here’s how you should report conditions both acute and chronic.

You may be operating under the notion that ICD-9 codes will always multiply into more definite options, and that’s the reason why the ICD-10-CM manual is so big. Though, that isn’t always the situation. Conditions necessitating two or more ICD-9 codes right now might be simplified into a single ICD-10 option.

Best bet: To determine whether you should report multiple codes or a single ICD-10- CM code, you need to read your coding guidelines. Keep an eye out for phrases like "use additional code" or "code first."

Capture Single Condition With Multiple Codes

True, you may find that a patient requires multiple ICD-10 codes to fully qualify the condition he or she has.

"Use additional code:" While you’re searching the Tabular List, you’ll find "use additional code" notes in conditions where you must use a secondary code to fully explain a condition. For example, you might nail on B95 (Streptococcus, staphylococcus, and enterococcus) as a secondary code to classify the bacteria causing the patient’s infection.

"Code first:" You might come across "code first" notes in the Alphabetic Index. This implies you must code the original condition first. For example, under the B39 (Histoplasmosis) category, you’ll see "code first associated AIDS (B20)."

"Code, if applicable, any causal condition first:" In case you see "Code, if applies, any causal condition first," then you may use this particular code as a main diagnosis while your physician hasn’t specified the causal condition. In case the physician has specified the causal condition, however, then you must code that as the principal diagnosis. For example, under N13.8 (Other obstructive and reflux uropathy), you’ll see "Code first, if applies, any causal condition, for instance enlarged prostate (N40.1)." That implies that in case the provider diagnosed an enlarged prostate, then you would code N40.1 as your main diagnosis.

Finally, you must be aware that you may require reporting multiple codes for late effects, complication codes, as well as obstetric codes.

Medical Billing and Coding Bonus concept: Suppose a patient has a condition that is both acute (subacute) and chronic. How must you report this? According to the ICD-10-CM Official Guidelines for Coding and Reporting, you must code both acute (subacute) and chronic. You should list the acute (subacute) code first. For example, a patient might have both acute thyroiditis (E06.0) along with chronic thryoiditis with transient thyrotoxicosis (E06.2). You would then report both codes with E06.0 listed first.

Medical Billing and Coding Tip: Report Multiple Conditions With Single Code

Though, rather than code multiple diagnoses for a condition, you may find that ICD-10- CM already has a single code that reflects a combination.

Combination codes (which are a single, unique code) identify:

• Two diagnoses
• A diagnosis with an associated secondary process (manifestation)
• A diagnosis with an associated complication

How You Must Report Late Effects (Sequela)

Here’s the code you must sequence first.

You might be aware of what late effects are in ICD-9, but how do you deal with them in ICD-10-CM? In fact, sequela is the new term in ICD-10 and by the sequela extension of "S" substitutes the late effects categories in ICD-9-CM. Read this article to know how your ICD-9 codes will change when ICD-10 implementation hits.

Example: Current late effect ICD-9 code 905.1 (Late effect of fracture of spine and trunk without mention of spinal cord lesion) will become M48.43xS (Fatigue fracture of vertebra, cervicothoracic region, sequela of fracture).

Follow these coding tips before you report a late effect code, so that your practice is never "late" collecting ethical reimbursement.

Medical Coding and Billing Tip 1: Review the Definition

"Sequela" is the new term used for late effects. Keep in mind that a late effect is the residual effect that takes place after the acute period of an illness or injury has terminated. For example, you’ll report a sequela ICD-10 code for the scar formation after a burn.

Medical Coding and Billing Tip 2: Time for Sequela Varies

You won’t find any time limit stating when you can start using a late effect code. Why not? For the reason that late effects vary. The residual effect may be obvious early, like in the case of a cerebral infarction, or it may take place months or years later, like an effect due to a previous injury.

Medical Coding and Billing Tip 3: Generally, You Need 2 Codes -- In This Order

When you code late effects, you’ll normally need two codes. You must sequence the condition or nature of the late effect first. You would code the late effect code second.

For instance, you might report M81.8 (Other osteoporosis without current pathological fracture) followed by E64.8 (Sequelae of other nutritional deficiencies [calcium deficiency]). The condition is osteoporosis, and the late effect is the calcium deficiency.

Exceptions: You may come across instances when you will report the late effect followed by a manifestation code.

A different situation is when the late effect has been expanded (at the fourth, fifth, or sixth character) to reflect the manifestation. For example instance, check out I69.191 (Dysphagia following nontraumatic intracerebral hemorrhage). The "following" means the definition includes the late effect.

You must never report the code for the acute phase of an illness or injury, even though that is what led to the late effect. Also, evade the activity codes Y93.- or External Cause Status codes Y99.- with sequela(e) codes.

Medical Coding and Billing Tip 4: Here’s How to Use Extension "S"

In case you’re looking at injury sequela(e) from ICD-10-CM’s Chapter 19, you’ll find most of the codes have a 7th character, which involves the code extension of "S." While using extension "S," you are required using both the injury code that precipitated the sequela and the code for the sequela itself. Bottom line: You’ll add the "S" only to the injury code, not the sequela code.

Diabetes Management: Follow These Simple Steps to Ace Diabetes Coding

Tip: Concentrate on diabetic complications related to existing episode of care.

Selecting the accurate diabetes diagnosis can seem quite complex, thanks to factors like your family physician seeing patients with more complicated cases than in the past and their treating diabetic manifestations. Use these expert medical billing and coding steps for perfect diabetes diagnosis coding to make certain that your ICD-9 codes validate the services you bill.

1. Select the Fourth Digit First

You’ll start code selection with diagnosis family 250.xx (Diabetes mellitus). Decide the fourth digit in line with the type of diabetic complication the patient has, if any.

Example: A patient comes with diabetic hypoglycemia. You must report 250.8 (Diabetes with other specified manifestations) as your first four digits. In case, on the other hand, the patient presents with diabetes devoid of any complications, your first four digits will essentially be ICD-9 code 250.0 (Diabetes mellitus without mention of complication).

Medical Billing and Coding Tip: Diabetes patients might have more than one complication. If this is the case, you must code only the complication most applicable to services the physician renders that day.

2. Ascertain the Type for Fifth Digit

The fifth digit of the diagnosis ICD-9 code delivers the final two pieces of information on the patient’s diabetic situation: the diabetes type (I or II) and whether or not it is controlled.

To choose the proper fifth digit, you should first know what the following listed ICD-9 descriptor terms mean:

· Type I – (The patient’s pancreatic beta cells no longer produce insulin. People with type I diabetes must take insulin. ICD-9 descriptors also refer to type I as "juvenile type" diabetes)

· Type II (The patient’s beta cells do not produce sufficient insulin, or the beta cells have developed insulin resistance. People with type II may not have to take insulin)

· Not stated as uncontrolled (The patient’s diabetes is managed sufficiently by diet and/or insulin)

· Uncontrolled (A patient can have uncontrolled diabetes when the physician documents that blood sugar levels are not acceptably stable under the current treatment regimen, when the patient is not in compliance with his diabetes management plan, or if the patient is taking medications for another illness that interfere with diabetes management)

Medical Billing and Coding Tip: First, you must check the physician’s documentation to see what sort of diabetes the patient has and whether the condition is controlled. Then select one of the following fifth digits:

· 0 (Type II or unspecified type, not stated as uncontrolled)

· 1 (Type I (juvenile type), not stated as uncontrolled)

· 2 (Type II or unspecified type, uncontrolled)

· 3 (Type I (juvenile type), uncontrolled)

Coding Tips: Evaluate Diagnosis and Management to Complete Crohn’s Claims

Focus on the full picture for maximum ethical reimbursement.

In case your gastroenterologist treats patients with Crohn’s disease (ileitis or regional enteritis), you are required to be very alert to look at diagnosis, management, as well as the treatment to correctly report your physician’s care. Here is a quick medical coding and billing refresher to help guide your Crohn’s disease CPT and ICD-9 coding.

Usage of Consult Codes for Initial Visits

In most cases, a patient with Crohn’s disease will typically present to your gastroenterologist’s practice as a referral patient from their primary care physician. In case documentation states that the aim of the visit is for an opinion or advice about the patient’s condition, then use consultation codes correct for the place of service. This initial visit must be considered as a consultation and must be reported using correct consultation codes 99241-99245 (Office consultation for a new or established patient ...).

CPT and ICD-9 Update: Starting from Jan. 1, 2010, Medicare stopped recognizing consultation codes. They need novel patient or established patient visits to be reported for the accurate place of service.

CPT and ICD-9 Coding Tip: Look for Symptoms Indicative of Crohn’s Disease

Symptoms of Crohn’s disease can contain chronic diarrhea (787.91, Diarrhea), chronic severe lower abdominal pain (789.0, Abdominal pain), blood in stools (578.1, Blood in stool), chronic nausea including or excluding vomiting (787.0, Nausea and vomiting), and weight loss. Signs and symptoms must be reported until Crohn’s disease is established.

Report Tests Conducted for Diagnosis

Your gastroenterologist might order numerous tests to confirm a diagnosis of Crohn’s disease (555, Regional enteritis) prior to initiating any management of the condition. Your gastroenterologist might order simple blood tests to check for ESR and WBC counts.

Moreover, your gastroenterologist might also gather a guaiac-based fecal-occult blood test (FOBT) (82270, Blood, occult, by peroxidase activity [e.g., guaiac], qualitative; feces, consecutive collected specimens with single determination….) as this test is very helpful thinking that the sensitivity levels revealed to lower bowel bleeding.

Medical Coding and Billing Tip: Guaiac based FOBT are not at all times ordered on patients. In case the patient only has anemia, your physicians might order the test. If the result is positive, the succeeding step could be endoscopy. Though, in case the patient has iron deficiency anemia or further signs of GI bleeding, we go straight to endoscopy. Only because the FOBT shows negative, it doesn’t imply that the patient doesn’t have Crohn’s.

CPT and ICD-9 Expert Coding Advice: Identify Colonoscopy Work

Another diagnostic measure that your gastroenterologist will carry out is a colonoscopy to check for signs of bleeding as well as inflammation. You can report this procedure with 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]).