There is no rest for the weary hme company as the Centers for Medicare & Medicaid Services (CMS) introduced substantial coding and policy changes in 2002. Of note, among those changes included within the December 2001 Region B DMERC Supplier Bulletin, which can be accessed at www.astar-federal.com, are revised criteria for insulin pumps, and coding changes for diabetic shoe inserts and for home blood glucose monitors and related supplies.

It is unsurprising that many policy and coding changes involve diabetes mellitus since, according to the American Diabetes Association (ADA), every year the United States spends $105 billion treating this disorder, which affects 5.9% of the population or 16 million people. However, by studying relevant background information regarding diabetes mellitus and learning the importance of ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) coding of diabetes mellitus in the HME environment, you can guide your company through these changes.

A Metabolism Disorder
Diabetes mellitus is defined as a chronic disorder of impaired carbohydrate, protein, and fat metabolism. This disorder is caused by either an absolute decrease in the amount of insulin secreted by the pancreas, or a reduction in the effectiveness of the insulin secreted.

Most diabetic patients fall into one of three categories: Type I diabetes, Type II diabetes, or gestational diabetes. Type I diabetes is characterized by the body’s failure to produce insulin at all. Type I diabetics require regular insulin injections to sustain life, and experience significant health problems when they do not follow the prescribed regimen for medication and diet.

Fortunately, Type I diabetes is relatively rare. According to ADA estimates, it accounts for only 5% to 10% of all diagnosed cases of diabetes.

Type II diabetes is more common in the Medicare population. In this disorder, insulin is produced, but either it is produced in insufficient quantity or the body is unable to use it adequately.

Type II diabetics usually do not require insulin. In some patients, however, insulin therapy may be needed to control persistent hyperglycemia. These patients are sometimes described as “insulin requiring,” but they are not insulin dependent. According to ADA estimates, Type II diabetes accounts for about 90% to 95% of all diagnosed cases.

The third common type, gestational diabetes, develops in 2% to 5% of all pregnancies but disappears after the pregnancy.

There are other specific types of diabetes that may result from genetic syndromes, surgery, drugs, malnutrition, infections, and other illnesses. However, such types of diabetes account for only 1% to 2% of all diagnosed cases of diabetes, according to the ADA.

Coding Worth Noting
When it comes to Medicare reimbursement, the type of diabetes is noted by the ICD-9-CM codes in section B of Certificates of Medical Necessity (CMNs). While it is true that only physicians can complete the ICD-9-CM codes in section B, HME providers who wish to verify medical necessity and protect their companies from fraud and abuse prosecution can benefit from learning how to read these codes. When you understand what the codes stand for, you can easily ensure that they support medical necessity for prescribed or provided items.

The basic code used to classify a disease or injury consists of three digits and is called a category. Most categories are expanded into subcategories by the addition of fourth digits, and many subcategories also include fifth-digit subclassifications that provide more specificity in coding. A decimal point separates the basic three-digit category code from its subcategory and subclassification.

Consider the code 250.00, which stands for diabetes mellitus without complication or unspecified and not mentioned as being uncontrolled. In this example, the fourth digit of 250.00 identifies the specified condition or manifestation associated with diabetes, while the fifth digit refers to the designation of Type I or Type II diabetes and whether the diabetes is controlled or uncontrolled. (For examples of the most common codes, see Table 1.)

Documentation by the physician in the patient’s medical record regarding whether the diabetes is controlled or uncontrolled is needed to assign the appropriate fifth-digit subclassification. In addition, documentation of the diabetes as Type I or Type II is also important for assignment of the fifth-digit subclassification. (For examples of the most common fifth-digit subclassifications, see Table 2.)

Keep in mind that without submission of an ICD-9-CM code, a claim will be rejected. If a diagnosis code requires five digits and only three or four are submitted on HCFA 1500 forms, the claim may be denied for failure to include a valid code.

Governmental scrutiny regarding diabetes coding will continue in the future. Therefore, it is important for HME dealers to keep abreast of ICD-9-CM codes and understand how they work.

Marcia Castillo, BAAS, RHIT, is a paralegal with Brown & Fortunato PC, Amarillo, Tex. She is a Registered Health Information Technician and specializes in medical record audits. Contact her at (806) 345-6354 or mcastillo@bf-law.com.

Resource
Diabetes Statistics. National Diabetes Information Clearing House. Available at: www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm.   Accessed March 15, 2002.