Coding to be more efficient and accurate

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Coding to be more Coding to be more efficient and accurate efficient and accurate

Why we need to code well!

$5749

Diabetes with renal or Diabetes with renal or cirulatory

cirulatorycomplicationcomplication

$4617

Diabetes with

Diabetes with NeurologicNeurologic complication

complication

$3836

Diabetes with acute Diabetes with acute complication complication

$2931

Diabetes with

Diabetes with opthamologicopthamologicor or unspecified complication unspecified complication

$1833

Diabetes without Complication Diabetes without Complication

Two parts to diabetic coding Two parts to diabetic coding

CPT codes in order entry area allow CPT codes in order entry area allow for Medicare payment and for

for Medicare payment and for population studies by Kaiser population studies by Kaiser

E & M coding in the LOS area allows E & M coding in the LOS area allows for patient mix payment (the other for patient mix payment (the other 70% of our patients)

70% of our patients)

Efficiency and accuracy are Efficiency and accuracy are paramount for maximal legal paramount for maximal legal reimbursement

reimbursement

CPT Coding

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What is Diabetic Dyslipidemia What is Diabetic Dyslipidemia ? ?

Diabetic dyslipidemia is the elevated Diabetic dyslipidemia is the elevated triglycerides and reduced HDL

triglycerides and reduced HDL- -cholesterol cholesterol in the blood caused by diabetes.

in the blood caused by diabetes.

It is It is not not an abnormality of LDL- an abnormality of LDL -C level. C level.

How to define it How to define it

NCEP ATP III definitions:NCEP ATP III definitions:

TriglyceridesTriglycerides

––Normal: < 150 mg/dLNormal: < 150 mg/dL –

–Borderline-Borderline-high: 150high: 150--199 mg/dL199 mg/dL –

–High: >High: >200 mg/dL200 mg/dL

HDLHDL--CholesterolCholesterol –

–Low: < 40 mg/dL in both men and womenLow: < 40 mg/dL in both men and women

We will use a conservative definition for diabetic We will use a conservative definition for diabetic dyslipidemia:

dyslipidemia:

TG >TG >200 mg/dL 200 mg/dL ANDANDHDLHDL--C < 40 mg/dLC < 40 mg/dL

How to define it How to define it

Mixed dyslipidemiaMixed dyslipidemiais a genetic disease that often cois a genetic disease that often co-- exists with diabetes and has both elevated triglycerides exists with diabetes and has both elevated triglycerides and elevated

and elevated LDLLDL--CC..

TG TG >>200 and HDL200 and HDL--C < 40 = DM DyslipidemiaC < 40 = DM Dyslipidemia

TG TG >>150 and LDL150 and LDL--C C >>100 = Mixed Dyslipidemia (is not 100 = Mixed Dyslipidemia (is not caused by diabetes)

caused by diabetes)

Both conditions should be treated with a statin to lower Both conditions should be treated with a statin to lower LDL

LDL--C to < 100 mg/dL.C to < 100 mg/dL.

Both diagnoses can be coded if present in the same Both diagnoses can be coded if present in the same individual.

individual.

How to code it How to code it

Compound Code 502144:Compound Code 502144:

DM 2 W LOW HDL AND HIGH TRIGLYCERIDE DUE TO DM DM 2 W LOW HDL AND HIGH TRIGLYCERIDE DUE TO DM (DIABETIC DYSLIPIDEMIA)

(DIABETIC DYSLIPIDEMIA)

Type Type DM LDM Lto bring up the diagnosisto bring up the diagnosis

Reports both ICDReports both ICD--9 codes: 250.80 and 272.49 codes: 250.80 and 272.4

Compound Code 502404 also exists:Compound Code 502404 also exists:

DM 2 W DIABETIC DYSLIPIDEMIADM 2 W DIABETIC DYSLIPIDEMIA

Type DM DYSL to bring up the diagnosisType DM DYSL to bring up the diagnosis

Reports the same codes and pays the same as 502144Reports the same codes and pays the same as 502144

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HealthConnect Codes HealthConnect Codes

Four relevant codes in HealthConnect:Four relevant codes in HealthConnect:

CORRECT:CORRECT:

DM 2 W LOW HDL AND HIGH TRIGLYCERIDE DUE TO DM DM 2 W LOW HDL AND HIGH TRIGLYCERIDE DUE TO DM (DIABETIC DYSLIPIDEMIA)

(DIABETIC DYSLIPIDEMIA)

DM 2 W DIABETIC DYSLIPIDEMIADM 2 W DIABETIC DYSLIPIDEMIA

HYPERLIPIDEMIA, MIXEDHYPERLIPIDEMIA, MIXED

NOT CORRECT:NOT CORRECT:

DM 2 W DIABETIC HYPERLIPIDEMIA, MIXEDDM 2 W DIABETIC HYPERLIPIDEMIA, MIXED

What is DM MAU? Why should I care?

DM DM microalbuminuriamicroalbuminuria::

––Definition: 30-Definition: 30-<300 mcg albumin/mg <300 mcg albumin/mg creatininecreatininein urine x 2 in in urine x 2 in 24 months in past (even if suppressed with ACEI etc later) 24 months in past (even if suppressed with ACEI etc later) ––Have not met criteria for overt CKD: MACROalbuminuriaHave not met criteria for overt CKD: MACROalbuminuriain in

urine >=300 x 2 for CKD 1/2

urine >=300 x 2 for CKD 1/2 ORORwith GFR low enough to with GFR low enough to qualify for CKD 3

qualify for CKD 3--5 (GFR < 2 SD for age).5 (GFR < 2 SD for age).

–

–One of 1st manifestations of systemic end organ damage in DMOne of 1st manifestations of systemic end organ damage in DM

Quality Implications:Quality Implications:

––2X CVD risk for death, 4x risk for ESRD2X CVD risk for death, 4x risk for ESRD

––Amenable to ALL therapy: lower risk for ESRD, lower risk of Amenable to ALL therapy: lower risk for ESRD, lower risk of death at 13 years

death at 13 years

––65yo+: over 15,000 missed pts with DM renal manifestations65yo+: over 15,000 missed pts with DM renal manifestations

DM MAU on the continuum before DM CKD DM MAU on the continuum before DM CKD

KPHC

code KPHC description Proactive Care

'CKD' Explanation 501065DM 2 w/ Diabetic Microalbuminuria DM MAU NO CKD stage & urine MAU/CR¹

>=30 but <300 x 2² 501066DM 2 w/ Diabetic CKD Stage 1 STG 1 GFR >=90 & MAU/CR >=300 x 2³ 501067DM 2 w/ Diabetic CKD Stage 2 STG 2 GFR 60-89 & MAU/CR>=300 x 2³ 501068DM 2 w/ Diabetic CKD Stage 3 STG 3 GFR 30-59 >3 months^4,5 501069DM 2 w/ Diabetic CKD Stage 4 STG 4 GFR 15-29 >3 months 501070DM 2 w/ Diabetic CKD Stage 5 STG 5 GFR <15 > 3 months 501071DM 2 w/ Diabetic End Stage Renal

Disease on dialysis Hemo or PD on hemodialysis or peritoneal dialysis

DM 2 KIDNEY DIAGNOSES

1MAU/CR=microalbumin/creatinine in mcg/mg creatinine with results during pregnancy excluded.

3 or urine protein/creatinine ratio >0.3 or 24 urine protein >300 mg/day on 2 sequential occasions in past even if 2'"x 2" means on 2 separate occasions in past in 24 month window even if more recent values are normalized with treatment of blood pressure or use of angiotensin converting enzyme inhibitors, angiotensin receptor blockers, renin inhibitors, aldosterone inhibitors, or diabetic control.

Using the chronic disease form Using the chronic disease form

Helps with both types of coding Helps with both types of coding

Is populated from the problem list Is populated from the problem list

Will populate the encounter diagnosis Will populate the encounter diagnosis section of the order entry screen section of the order entry screen when completed

when completed

Completing at least three chronic Completing at least three chronic diagnosis allows for higher level of diagnosis allows for higher level of LOS

LOS

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The chronic disease form

The chronic disease form Completed Chronic Disease Form Completed Chronic Disease Form

Completed encounter Diagnosis Completed encounter Diagnosis

form form . .diag diag completes the documentation completes the documentation

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Maximizing Reimbursement Maximizing Reimbursement

Manifestations in order of Manifestations in order of

reimbursement:

1. Renal or Peripheral Circulatory 1. Renal or Peripheral Circulatory 2.

2. Neurologic Neurologic or other specified or other specified 3. Diabetes with acute complications 3. Diabetes with acute complications 4. 4. Ophthamologic Ophthamologic or unspecified or unspecified 5. Diabetes without complication 5. Diabetes without complication

Remember Many of the diagnosis Remember Many of the diagnosis

are additive?

250.40 Renal Manifestations due to DM2 250.40 Renal Manifestations due to DM2 585.3 CKD 3

585.3 CKD 3

250.80 DM2 w/ other unspecified manifestations 250.80 DM2 w/ other unspecified manifestations

(for mixed

(for mixed hyperlipidemia hyperlipidemia) ) These payments add together from

These payments add together from medicare medicare, but , but they must be linked to diabetes to get

they must be linked to diabetes to get maximimum

maximimum payment: use 500000 codes payment: use 500000 codes (combined codes)

(combined codes)

*

This payment is actually This payment is actually downcodeddowncodeddue to being a secondary diagnosis, but there is due to being a secondary diagnosis, but there is still an additional payment

still an additional payment

500000 Codes 500000 Codes

The 500000 codes automatically combine The 500000 codes automatically combine Diabetes with complications. They Diabetes with complications. They attribute the complication to diabetes attribute the complication to diabetes which

which upcodes upcodes the payment. You should the payment. You should never be coding a diabetic without using never be coding a diabetic without using the 500000 codes. I keep them in my the 500000 codes. I keep them in my diabetes coding preference list along with diabetes coding preference list along with codes for foot exam and smoking histories codes for foot exam and smoking histories so that I can just click down all the so that I can just click down all the diabetic diagnoses

diabetic diagnoses . .

500000 codes: examples

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Just the additional coding of mixed Just the additional coding of mixed hyperlipidemia

hyperlipidemia or erectile dysfunction or erectile dysfunction increases the payment by $3500.

increases the payment by $3500.

Of course, you must actually ask Of course, you must actually ask about these complications, include about these complications, include them in your note and in your them in your note and in your assessment and plan

assessment and plan

Do you ask your patients to roll up Do you ask your patients to roll up

their pant legs?

Diabetic Diabetic Dermopathy Dermopathy has a separate has a separate code:

code:

500784 DM2 w Diabetic 500784 DM2 w Diabetic Dermopathy Dermopathy

This gets paid like diabetes with an This gets paid like diabetes with an unspecified manifestation: (this is unspecified manifestation: (this is NOT additive to the mixed

NOT additive to the mixed hyperlipidemia

hyperlipidemia or any of the or any of the neuropathies)

neuropathies)

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USE CORRECT LINK TO LOOK FOR USE CORRECT LINK TO LOOK FOR MICROALBUMIN/CREATININE RESULTS MICROALBUMIN/CREATININE RESULTS

IN KPHC IN KPHC .brieflab[malbcreat:100

MICROALBUMIN/CREATININE 167.5 01/26/2009 MICROALBUMIN/CREATININE 185.1 05/23/2008 MICROALBUMIN/CREATININE 122.8 07/09/2007 MICROALBUMIN/CREATININE 41.2 05/10/2007 MICROALBUMIN/CREATININE 47.8 06/23/2006

.LASTMICROALBPANEL

MICROALB 223.6 01/26/2009 MICROALBUMIN/CREATININE 167.5 01/26/2009 PROT/CREAT UR 0.15 10/07/2006