1. DIABETES MELLITUS Coding and Documentation for Compliance and Financial Reimbursement
2005 Revisions

2. Definition Of HCC And Financial Impact
The CMS/Medicare Risk Adjusted Reimbursement Model is based on chronic, additive conditions or Heirarchical Condition Categories (HCCs)
MD documentation/reporting of patient diagnosis determines 50% of the health plan payment to SRSMG for Senior HMO patients
Payments are higher for less healthy members and lower for more healthy members
Coding of Diabetes and the Manifestations to the highest
level of specificity has significant financial impact to SRSMG reimbursement under this new model.

3. What’s the Big Deal? The risk adjusted portion of the premium is
increasing each year; soon to be 100% in 2007
Current year risk adjustment percentage is 50%
Historically, Managed Care has not focused on
diagnosis coding at the physician level
The quality of diagnosis coding must improve in
order to maintain the same $ or to increase $ due
to a patient’s health status

4. Risk Adjustment Factor Scores 2004/2005
Note: Some categories have a hierarchy, such as Diabetes, in such categories, only the highest HCC would “count”
$ 3,152
1,852
250.4x D. w/ renal or peripheral circulatory manifestations
HCC15
$ 2,277
$ 1,338
250.6x D. w/ neurologic manifestations
HCC16
$ 1,613 $
x D. w/ acute complications
HCC17
$ 1,415 $
250.5x D. w/ ophthalmic manifestations
HCC18 $ $
Diabetes w/ no complications
HCC19
2005
50%
Annual Reimburs.
2004
30%
HCC
These figures are an additional reimbursement on top of Demographics etc…
Example: Question recently from a group, How should the Doc code a Member with Diabetes with Renal Failure? (The Doc felt he should code Diabetes 250.4x only) Answer: Should be coded with 250.4x (Diab w/Renal) and 586 (Renal Failure NOS) because both DX fall into the Risk model and are cumulative, thus you would not only receive the $1,852 for HCC15 but also aprox. $1,396. for HCC131 on top any other HCC’s and demographics.

5. 2004 SRS HCC Audit Projects Eight Coders 7,848 records reviewed
2,301 hours
Over 4,085 HCCs identified
2003 and 2004 data was reviewed to identify HCCs documented but not reported.
SHC cap increase due to 2004 HCC projects = $1.9m SRS portion = $511,249
Diabetes Mellitus has been identified as the #1 priority for coding/documentation improvement and financial opportunity.

6. DM Type I versus Type II
The foundation of accurate clinical documentation and reporting of diabetes begins with the identification of the Disease Type

7. TYPE I TYPE II Pancreas produces no insulin
Insulin dependent for survival
TYPE II
Pancreas produces insufficient
amount of insulin Or
Insulin resistant

8. DM TYPE
Once the DM Type is selected, the controlled / uncontrolled status of diabetes is determined by the findings from the current patient encounter

9. 250 . X X 1st 3 digits define the DM Dx
When presenting, walk through each digit explaining how it was chosen, reviewing previous material. Emphasize that no additional 250 code is needed to report a single manifestation linked to the diabetes. (reviews have found MDs reporting the diagnosis of DM then using another code to separately report the complication)
1st 3 digits define the DM Dx
4th digit defines the manifestation
(if applicable)
5th digit defines type and control

10. Defining Controlled 250.X0 HbA1C < 7* 250.X1
Diagnosis
Definition
Supporting Labs
250.X0
250.X1
Diabetes Mellitus Type II Controlled
Diabetes Mellitus Type I Controlled
HbA1C < 7*
Notice we have an “X” in the 4th digit because we have not yet established the manifestations, only the DM dx with the 250 and the 5th digit “0” or “1” for both the DM Type and the controlled/uncontrolled status.
* Per ADA guidelines

11. Defining Uncontrolled
Diagnosis
Definition
Supporting Labs
250.X2
250.X3
Diabetes Mellitus Type II Uncontrolled
Diabetes Mellitus Type I Uncontrolled
HbA1C >7*
* Per ADA guidelines

12. Controlled or Uncontrolled?
Type II diabetic patient without complications
presents for a visit, last recorded HbA1C of 7 is
on file dated 3 months prior. Patient states he
was on vacation and his blood sugars had been
running high. Physician performs a random
sugar test (finger stick) and the result is
200 mg/dl

13. Answer:  Uncontrolled
Assign an ICD-9 code based on the
current encounter, not on the previously
documented HbA1C
Code: DM II, uncomplicated,
uncontrolled
Patient is uncontrolled at the time of the visit
Review again how code was derived

14. without Manifestations*
Diabetes Code Assignment
Diabetes Mellitus
without Manifestations*
250.0X
Select Type
Type I
Type II
Controlled?
Controlled?
Yes No
Yes No
250.01
Type I
250.03
Type I
250.00
Type II
250.02
Type II
*For DM with manifestations, refer to DM ICD-9 reference tool

15. DM In Pregnancy 648.8: 5th Digit describes episode of care
Pregnancy in a patient with known DM:
648.0X AND 250.XX
Ex: Patient with known diabetes presents to PCP during the 3rd trimester.
Gestational Diabetes arising in pregnancy: X
Ex: Pregnant patient with an abnormal glucose tolerance test result:
648.8: 5th Digit describes episode of care
0-Unspecified episode of care
1-Delivered with or w/o mention of antepartum condition
2-Delivered with mention of postpartum complication
3-Antepartum complication
4-Postpartum complication

16. Manifestation Risk Areas Associated with Diabetes
Nephropathy (in other diseases)
Microalbumin (>30 on two specimens)
Nephrotic Syndrome
Frank proteinuria (>3 gm/24 hr collection)
Diabetic Retinopathy
Macular edema or neovascularization (on photo or dilated exam)
Polyneuropathy in DM
Loss of protective sensation
(failed 2/5 sites microfilament test)
Peripheral Angiopathy
Intermittent Claudication, decreased pulses or
abnormal ABI
Ulcerations
5/24/04 Add clinical indications for coding Ulcerations due to DM. Monica will get input from Dr. Trapp and enter.

17. How to Document Manifestations
A direct causal relationship between
diabetes and the manifestation must
be documented
Ex. “Peripheral Neuropathy due to Type II Diabetic,
Controlled”
Include statement on referencing diabetes educator’s note.

18. Terms/Words Not to Use when documenting DM
Do Not Use
Use
(Use these phrases to support corresponding 4th/5th digit)
“DM”,
“probably uncontrolled”
“sub-optimal”
“poorly controlled”
“history of”
DM (I or II) Controlled
DM (I or II) Uncontrolled
“borderline”
“pre-diabetes”
“most likely”
Impaired fasting glucose
Abnormal glucose results Abnormal glucose tolerance test (oral)
“DM
“Peripheral Neuropathy”
Peripheral neuropathy “due to”. “associated with”, “secondary to” or “complicated by” DM II Controlled
(These phrases will result in coding controlled status with LOWEST risk adjustment)

19. 2005 ICD-9 Changes
The descriptions to the 5th digits of code 250.XX have had the following descriptors removed:
[non-insulin dependent type]
[adult-onset type]
NIDDM
[insulin dependent type]
IDDM

20. DM ICD-9 Changes 2005 New fifth digit definitions:
0 type II or unspecified type, not stated as uncontrolled
1 type I [juvenile], not stated as uncontrolled
2 type II or unspecified type, uncontrolled*
3 type I [juvenile], uncontrolled
Revised to remove from description :
NIDDM, IDDM, adult onset type & insulin dependent type
New code: *V58.67 long term (current) insulin use

21. New 2005 Medicare Coverage for DM Screening
Diabetes Screening Now Covered:
Every 12 months
82950 Glucose, post glucose dose (includes glucose) OR
82947 Glucose, quantitative, blood AND
82951 Glucose, tolerance test (GTT), three specimens (includes glucose)
ICD-9 V77.1 Special screening for diabetes mellitus

22. New 2005 Medicare Coverage for DM Screening
DIABETES SCREENING Covered for Pre Diabetics
Every 6 months
82950 Glucose, post glucose dose (includes glucose) OR
82947 Glucose, quantitative, blood AND
82951 Glucose, tolerance test (GTT), three specimens (includes glucose)
Pre-Diabetic Definition:
Fasting glucose level mg/dL- 2hr
Post glucose challenge of mg/dL
ICD-9 V77.1 Special screening for diabetes mellitus

23. Questions…………………

24. Coding Contacts