Anyone who has worked in a medical practice knows that one of the toughest types of patients to code correctly are patients who are prediabetic. What to do with these patients—how to make sure you are capturing all your charges correctly—is a real issue. The American Diabetes Association (ADA) has reported that 86 million American adults have prediabetes as of 2012. There is not a practice in the country that doesn’t treat patients with prediabetes.
New Code - New Approach to Chronic Care
What makes the coding dilemma easier now is that on October 1, 2016, CMS introduced a new ICD10 code specifically identifying a patient with prediabetes. This code, R73.03, should be used in place of R73.09, a non-specific code for abnormal blood glucose that was previously used to identify potential prediabetes in a patient. By establishing a more specific code, the process is simplified for tracking these patients within your EHR. It also assures correct payment by Medicare and commercial insurance plans/payers for care provided to patients who are at increased risk of diabetes.
Correctly identifying someone as having prediabetes is important for your chronic care management. All new payment models require practices to provide increased assessment of patients for existing and potential chronic conditions. Accurately coding patients with prediabetes will allow you to create a prediabetes registry and work with these patients to prevent the onset of type 2 diabetes. Additionally, using the prediabetes ICD10 code will give you a tracking mechanism for referring and monitoring these patients’ participation in a Diabetes Prevention Program (DPP).
The technical definition of the R73.03 Prediabetes is an interim diagnosis used to describe an elevated blood glucose level that is higher than normal but not yet high enough to be considered type 2 diabetes. With no intervention, the condition is expected to become type 2 diabetes within 10 years. A fasting blood glucose level of 100 to 125 mg/dl typically warrants a diagnosis of prediabetes, and the patient is then referred to a DPP to be educated about diet and exercise patterns for preventing the progression of prediabetes to type 2 diabetes. This definition is not age specific.
What Is Prediabetes?
Prediabetes, clinically speaking, means that a person’s glucose level is elevated but not high enough to be classified as diabetes. This diagnosis can be confirmed by different lab test results:
Figure 1: Laboratory Test Results to Confirm Diagnosis of Prediabetes
|Laboratory Test||CPT Code||Test Result to Support Diagnosis of Prediabetes|
|Fasting Glucose||82947||100 – 125 mg/dl|
|Random Non-Fasting Glucose||82950||140 – 199 mg/dl|
|2-Hour Glucose Tolerance Test (GTT)||82951||140 – 199 mg/dl|
|Diabetes A1C||83036||5.7 – 6.4%|
Most payers will require a practice to verify a patient’s status as having prediabetes with a confirmatory lab test even if a patient’s prediabetes risk assessment shows a higher risk for diabetes.
How to Identify Individuals with Prediabetes
The first step in establishing correct coding procedures for prediabetes is being able to identify patients with prediabetes. For patients who are new to your practice and for any established patients over 45 years old (or a younger age based on risk assessment) who have not been screened for diabetes, you should always start by having the patient take a prediabetes risk assessment. The questions covered in the prediabetes risk assessment include:
A copy of the American Diabetes Association (ADA) Diabetes Risk Assessment can be found at: http://main.diabetes.org/dorg/PDFs/risk-test-paper-version.pdf. The seven questions included on the prediabetes assessment should only take a few minutes to answer.
If your patient receives enough points to classify them as having prediabetes, your next step should be to confirm the diagnosis of prediabetes through one of the lab tests listed on page 2. Once the diagnosis of prediabetes is confirmed with one of the four blood tests, the “Prediabetes” (ICD10 R73.03) code should be added to the patient’s problem list in the medical record within the EHR. That way, you will be able to easily track the patient for DPP referrals and follow-up.
How to Code for Lab Tests that Are Part of a Diabetes Screen with/without Diagnosis of Prediabetes
For non-Medicare patients who are identified as prediabetic through an assessment form, your practice should contact the patient’s insurer to see which lab tests will be covered and at what intervals. Some payers may cover this testing as part of a well visit preventive screen without requiring a co-pay or deductible.
For Medicare patients, CMS will pay for an individual to be screened for diabetes, but it is important that you correctly identify the patient’s status at the time of ordering the screening tests. The lab tests may be coded differently for different patients depending on the information gathered from the patient’s prediabetes risk assessment. The TS modifier is used to identify that the patient meets the criteria for diabetes screening for a beneficiary who meets the *definition of prediabetes, screening diagnosis code Z13.1 is required in the header diagnosis section of the claim and modifier “TS” is to be reported on the line item(s) for the lab CPT codes.
Figure 2. Coding for Lab Test for Prediabetes Screen
|Code for Lab Test||Use in These Circumstances||Payer Coverage|
Encounter for screening for diabetes mellitus
(modifier TS goes on the lab codes or orders)
|If any one of these conditions exist, then use the TS modifier:
|Z13.1 Encounter for screening for diabetes mellitus (modifier TS goes on the lab codes or orders)||If any twoof these conditions exist, then use the TS modifier when ordering:
|Z13.1 Encounter for screening for diabetes mellitus|| Do not use the TS modifier if:
Referral to a Diabetes Prevention Program Patients who are identified as having prediabetes will be eligible to participate in a community-based education program known as a DPP. DPPs exist in Ohio under the National DPP established by the CDC ( https://www.cdc.gov/diabetes/prevention/index.html).
Figure 3. Ohio has 29 CDC-approved DPPs
Steps to Establish Your Prediabetes Screening Program
In summary, to correctly identify a patient as prediabetic and to monitor them on a regular basis; the following steps should be taken:
We would like to thank Diane Zucker, M.Ed., CCS-P for providing her technical expertise with this article. In addition to the article, she will be joining Cathy Costello for our February 14, 2017, webinar at noon on this topic. You can register at: https://attendee.gotowebinar.com/register/4976294349724263425. Here is Diane’s Bio:
Diane Zucker, M.Ed., CCS-P is a health care management and reimbursement consultant who has spent the last 31 years as a consultant providing physicians, practices and various agencies and facilities educational programs. These programs and services are opened and focused on real world information for the complex maze of documentation, coding and compliance. She has a Master’s in Education and a Bachelor’s Degree in Social Work from Kent State University with additional coursework in health care management and reimbursement. Education programs have focused on the practical aspects of documentation and coding for all levels of providers. Prior to consulting, she worked as a psychiatric social worker, counselor for the Bureau of Vocational Rehab and as a medical social worker. Diane is a certified CPT coder and ICD10 CM trainer through AHIMA since 1997.
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Medicare Preventive Services Bulletin: ICN 006559 October 2016 updated for ICD10 codes