Your practice works hard to preserve vision for your patients with diabetes. Here’s what your revenue cycle management team needs to know to collect the full reimbursement your practice deserves.
Value-based reimbursement makes thorough documentation more important than ever.
Remember, diabetes potentially affects a much larger patient pool in your eye care practice than simply your diabetic retinopathy cases. The presence of the disease often makes medical decision making (MDM) more complicated for ocular conditions and treatments, notes Rhonda Buckholtz CPC, CRC, CPMA, CDEO, CHPSE, CPCI, COPC, chief compliance officer at Century Vision Global. To make sure that your physician gets adequately reimbursed for complex MDM, you should focus on medical necessity and provide diagnosis codes for the secondary, co-morbid conditions that clinicians are considering when they make plans of care.
As with all chronic conditions, you should make sure that your claims for patients with diabetes “tell payers the whole story,” Buckholtz explains. If you don’t have enough information from the patient’s primary care doctor or referring physician to accurately code for diabetes or other co-morbid conditions, get it and document it, she urges.
“Suppose we’re looking at a diabetic patient with retinal conditions,” Buckholtz said in the on-demand webinar Understanding Medical Necessity and How It Ties To Correct Coding. With a new patient, the physician typically reviews labs and history of diabetes to determine the eye problem’s severity and how the patient controls or doesn’t control the situation. If the doctor sends the patient for any additional, outside tests, that’s an additional workup, she adds. “If the same patient returns for a follow up and his blood sugar results have declined, the provider must then look for alternative treatment options—which requires more MDM than the patient who follows up and is stable and current with other treatment.”
MIPS Clinical Quality Measures for Diabetes
If your practice is participating in MIPS, don’t forget that there are some clinical quality measures (CQMs) for diabetes and diabetic retinopathy, reminds Mike Schmidt, Vice President, client success and regulatory affairs at Eye Care Leaders. They are:
Measure 1: Diabetes: Hemoglobin A1C Poor Control
Measure 19: Diabetic Retinopathy; Communication with the Physician Managing Ongoing Diabetes Care
Measure 117: Diabetes: Eye Exam
Note: CMS has removed Measure 18 (Diabetic retinopathy documentation of macular edema and severity of diabetic retinopathy) from 2019 MIPS reporting.
Keep Your Eyes on Diagnostic Testing
Remember that Medicare covers annual glaucoma screenings for patients with diabetes, notes Torrey Kim in Ophthalmology Coding Alert. Having diabetes puts patients into one of the four ‘high-risk’ groups. (The other three are patients with family histories of glaucoma, African Americans aged 50 or older, and Hispanics aged 65 or above.) Report one of the following codes, depending on whether the physician provided or supervised the service:
G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist)
G0118 (Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist)
The documentation must also show that you performed the covered screening services, and you should include the diagnosis code Z13.5 (Encounter for screening for eye and ear disorders) on your claim, Kim recommends, citing a recent NGS webinar on this topic.
“It’s important to remember that this is a screening,” Kim stresses. “Many Medicare recipients will inquire about having this service performed when they have already been diagnosed with some form of glaucoma. Once a glaucoma diagnosis has been established, medical examinations are warranted and the patient no longer qualifies for a screening.”
Make sure you’re clear on payer rules for fundus photography. Most payers will reimburse you for 92250 (Fundus photography with interpretation and report) only once per year, Kim cautions. Any more than that triggers red flags for an audit. Diabetic retinopathy that is progressing rapidly could be a medical necessity-related exception to this general rule, however. “Fundus photos may be of value in the documentation of rapidly evolving diabetic retinopathy. In the absence of prior treatment, studies would not generally be performed for this indication more frequently than every six months,” notes Part B payer First Coast Service Options.
ICD-10 Coding Tips
With almost 250 diagnosis codes to choose from in ICD-10, diabetes coding can seem overwhelming at first glance. Eye care practices, however, most often use codes in the E11 (Type 2 diabetes mellitus) or E10 (type 1 diabetes mellitus series), so that helps narrow down the choices. Most often, you’ll be coding to the fourth or fifth character in order to communicate the specificity required.
Within both series, a “3” as the fourth character communicates that there is a diabetes-related eye disease or complication–for example, E11.32 for Type 2 diabetes with mild nonproliferative diabetic retinopathy, point out Joy Dugan and Jay Shubrook in Clinical Diabetes. (If you’re training new coders and billers, their journal article is an excellent primer on diagnosis coding for diabetes and diabetes-related conditions).
If the patient is using insulin to control Type 2 diabetes, look for Z79.4 (Long term (current) use of insulin) or Z79.84 (Long term (current) use of oral hypoglycemic drugs). Even though these descriptors contain the phrase ‘long term,’ these codes are appropriate even if the insulin treatment has recently begun, as long as the plan is for the patient to take insulin for a period of time, Dugan and Shubrook explain. Z96.41 indicates that an insulin pump is involved.
What about “prediabetes?”
If you see the term “prediabetes” in a clinician’s note, use R73.09, which covers abnormal fasting glucose, abnormal glucose tolerance or elevated A1C in the prediabetes range, Dugan and Shubrook advise.