Prediabetic Screening and Coding

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[1]:

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:

  • Age
  • Sex
  • Weight: with a Body Mass Index (BM) over 25 (in ICD10 coding this is a BMI from Z68.25 and higher)
  • Family history of diabetes: identified in ICD10 as Z83.3 Family history of diabetes mellitus
  • History of high blood pressure: diagnoses in the ICD10 from the following: I10 Essential (primary) hypertension; R03.0 Elevated blood-pressure reading, without diagnosis of hypertension I16.0 Hypertensive urgency; I16.1 Hypertensive emergency and other related hypertensive diagnoses in the I11, I12 and I13 families of ICD10 codes
  • Physical activity: identified in ICD10 as Z72.3 Lack of physical exercise
  • Gestational diabetes mellitus: identified in ICD10 as Z86.32 Personal history of gestational diabetes

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
Z13.1
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:
  • Patient has hypertension
  • Patient has BMI > 30 kg/m2
  • Patient has dyslipidemia
  • Patient has previously elevated glucose
  • Medicare will pay for testing with no co-pay or deductible for Medicare beneficiaries[2]
  • For Medicare, test can be repeated every 6 months (maximum 2x in a calendar year)
  • Check with other payers for specific coverage
  • 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:
    • Patient has family history of diabetes
    • Patient is older than 65 years
    • Patient’s BMI is between 25 and 30 kg/m2
    • Patient had gestational diabetes (or baby weighed > 9 lbs. at birth)
  • Medicare will pay for testing with no co-pay or deductible for Medicare beneficiaries
  • For Medicare, test can be repeated every 6 months (maximum 2x in a calendar year)
  • Check with other payers for specific coverage
  • Z13.1 Encounter for screening for diabetes mellitus   Do not use the TS modifier if:
    • Patient has never been screened for diabetes
    • Patient has been screened for diabetes but test result shows patient is NOT prediabetic
  • Medicare will pay for testing with no co-pay or deductible for Medicare beneficiaries
  • For Medicare, test can be repeated every year
  • Check with other payers for specific cover

  • 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:

    • Administer the Prediabetes Risk Assessment to patients with identified risk factors. The ADA version can be found at: http://main.diabetes.org/dorg/PDFs/risk-test-paper-version.pdf
    • Check with payers to determine coverage for prediabetes lab testing, so you can advise your patients if the co-pay and deductibles are covered for the lab work, if needed.
    • Depending on your patient’s score on the Prediabetes Risk Assessment, order appropriate lab tests to confirm diagnosis of prediabetes (fasting glucose, non-fasting random glucose, 2 hour GTT, or diabetes A1C). Be sure to include coding related to patient’s status:
    • §TS modifier if patient meets certain risk criteria stated above;
    • §no modifier if patient has never been screened or if patient has been screened and determined to have prediabetes.
    • If test results confirm diagnosis of prediabetes, list prediabetes (R73.03) in the patient’s problem list in his/her medical record and code it on your claims form.
    • If patient has prediabetes, refer to a DPP (list of DPP sites can be found at: https://nccd.cdc.gov/DDT_DPRP/CitiesList.aspx?STATE=OH)
    • Create a registry every quarter of patients diagnosed with prediabetes. Follow up with them to retest their glucose at appropriate intervals and to encourage participation in a DPP.

    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.

    For a full PDF of this story, click here.

     

     

     

     



    [1] American Diabetes Association: www.diabetes.org/diabetes-basics/statistics/

    [2]Medicare Preventive Services Bulletin: ICN 006559 October 2016 updated for ICD10 codes

    For better mobile viewing, please turn your phone to a vertical position.

    OK

    Please maximize your browser window for the best browsing experience.

    OK