Fall 2015



Asthma Diagnosis and Management Guidelines

The prevalence of asthma in low-income communities and among African Americans and Latinos is well established.  So it comes as no surprise that by every available indicator—ED visits, hospitalizations, deaths—the Bronx is the epicenter of the condition in New York City and New York State.

It is essential, therefore, that primary care physicians remain aware of the possible presence of asthma in patients in their practice and follow evidence-based guidelines in treating patients with the condition. 

All patients with a diagnosis of asthma should have a recent assessment of their condition, including severity and control, from the past year. At a minimum, all patients with asthma should have an Asthma Action Plan, understanding the triggers that cause an episode, know how to use an inhaled corticosteroid (ICS) pump and know what to do if they have an attack.

Guidelines from the National Asthma Education and Prevention Program for diagnosing and managing asthma can be accessed at https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf  

Documenting Diabetes Mellitus under ICD-10

In ICD-10, diabetes mellitus falls into five major categories, two of which are the predominant primary care conditions:

  • E10: Type 1 diabetes mellitus
  • E11: Type 2 diabetes mellitus

 The other 3 categories are rarely encountered in primary care:

  • E08: Diabetes due to underlying condition – This category is reserved for individuals who develop diabetes secondary to an underlying condition such as a malignancy, malnutrition or pancreatitis.
  • E09: Drug or chemical-induced diabetes mellitus
  • E13: Other specified diabetes mellitus – This category includes diabetes mellitus due to genetic defects of beta-cell function and insulin action, as well as post-procedural diabetes mellitus.

 To properly document these conditions for ICD-10 coding, take the following steps:

1. Specify Type 1 or Type 2

2. Indicate the presence of hyperglycemia or hypoglycemia (to represent those cases where diabetes is poorly controlled)

E11.64 … with hypoglycemia

E11.641 ... with coma

E11.649 ... without coma

E11.65… with hyperglycemia

3. Specify complications to a very specific degree.

The additional characters in the diabetes codes are essentially the same for both Type 1 (E10) and Type 2 (E11). The list of Type 2 codes, below, shows the degree of specificity required. It is important to note the specific wording of each diagnosis code. For instance, if your patient has diabetes mellitus and chronic kidney disease, you have to specify both the cause and effect for both the diabetes and the secondary condition to be properly coded.

E11.0 Type 2 diabetes mellitus with hyperosmolarity

E11.00 ... without nonketotic hyperglycemic hyperosmolar coma

E11.01 ... with coma

E11.2 Type 2 diabetes mellitus with kidney complications

E11.21 ... with diabetic nephropathy

E11.22 ... with diabetic chronic kidney disease (an additional code is needed for the   CKD stage

E11.29 ... with other diabetic kidney complication

E11.3 Type 2 diabetes mellitus with ophthalmic complications

E11.31 ... with unspecified diabetic retinopathy

E11.311 ... with macular edema

E11.319 ... without macular edema

E11.32 ... with mild nonproliferative diabetic retinopathy

E11.321 ... with macular edema

E11.329 … without macular edema

E11.33 ... with moderate nonproliferative diabetic retinopathy

E11.331 … with macular edema

E11.339 … without macular edema

E11.34 ... with severe nonproliferative diabetic retinopathy

E11.341 … with macular edema

E11.349 … without macular edema

E11.35 ... with proliferative retinopathy

E11.351 … with macular edema

E11.359 … without macular edema

E11.36 ... with diabetic cataract

E11.39 ... with other diabetic ophthalmic complication

E11.4 Type 2 diabetes mellitus with neurologic complications

E11.40 … with diabetic neuropathy, unspecified

E11.41 ... with diabetic mononeuropathy

E11.42 ... with diabetic polyneuropathy

E11.43 ... with diabetic autonomic (poly) neuropathy

E11.44 ... with diabetic amyotrophy

E11.49 ... with other diabetic neurological complications

E11.5 Type 2 diabetes mellitus with circulatory complications

E11.51 … with diabetic peripheral angiopathy without gangrene

E11.52 … with diabetic peripheral angiopathy with gangrene

E11.59 … with other circulatory complications

E11.6 Type 2 diabetes mellitus with other specified complications

E11.61 ... with diabetic arthropathy

E11.610 ... with diabetic neuropathicarthropathy

E11.618 ... with other diabetic arthropathy

E11.62... with skin complications

E11.620 ... with diabetic dermatitis

E11.621 ... with foot ulcer (an additional code is needed for the site of the ulcer

E11.622 ... with other skin ulcer (an additional code is needed for the site of the   ulcer

E11.628 ... with other skin complications

E11.63 ... with oral complications

E11.630 ... with periodontal disease

E11.638 ... with other oral complications

E11.64 … with hypoglycemia

E11.641 ... with coma

E11.649 ... without coma

E11.65… with hyperglycemia

E11.69… with other specified complications

E11.8 Type 2 diabetes mellitus with unspecified complications

E11.9 Type 2 diabetes mellitus without complications

As shown in these examples, there are numerous codes that document the type of diabetes, the severity of the condition and the complications of the disease. Remember, when the patient has multiple complications, correct coding requires you to document and code each complication separately.

Influenza and Pneumococcal Immunization Guidelines

Flu season is here, and immunization is recommended for all patients six months old and above, including pregnant women, and is especially important for all patients age 65 and older.

This is also a time to offer a pneumococcal immunization to your patients and to check their medical record to determine if other recommended immunizations, including tetanus and zoster , are indicated. 

Medicare (Part B), Medicaid and most commercial insurers cover both the costs of the flu vaccine and its administration by recognized providers. There is no Medicare coinsurance or co-payment applied to this benefit, and a beneficiary does not have to meet his or her deductible to receive this benefit.

Information for clinicians about influenza and vaccination recommendations from the CDC is available at http://www.cdc.gov/flu/professionals/acip/index.htm.

Because health care workers are at increased risk for acquiring influenza infection and transmitting disease to their patients, colleagues and families, it is recommended that all health care workers should receive annual influenza vaccination, especially if they are in close contact with high-risk patients. 

The pneumococcal immunization is strongly recommended for adults beginning at age 65.  Pneumococcal vaccine coverage rates among New Yorkers aged 65 and older have been persistently below national goals. 

Recommendations about the administration of pneumococcal vaccine for adults can be found at http://www.cdc.gov/vaccines/vpd-vac/pneumo/vac-PCV13-adults.htm

It is not necessary to ask patients to show their immunization record prior to administering the pneumococcal vaccines or to review the complete medical record if it is not available. For patients competent to make their own decisions, you may rely on the patient’s verbal history to determine prior pneumococcal vaccination status. If a patient older than 65 is uncertain about his or her vaccination history, administer the vaccine.

Medicare (Part B) provides coverage for one pneumococcal vaccine for all beneficiaries. There is no coinsurance or co-payment applied to this benefit, and a beneficiary does not have to meet his or her deductible to receive this benefit. Medicare will also cover a pneumococcal vaccine for persons at the highest risk if five years have passed since the last vaccination, but routine revaccinations of beneficiaries who are not at the highest risk are not appropriate.

Annual ACO CAHPS Survey Underway

Patient experience is one of the metrics CMS uses to determine the quality performance of ACOs.  The assessment is based on a CAHPS survey of a randomly selected sample of attributed beneficiaries.  The survey is conducted by a contractor chosen by the ACO.

The mandatory 2015-2016 CAHPS survey for the Montefiore ACO has begun, with letters being mailed by Morpace, Montefiore’s vendor, to 860 beneficiaries.  Follow-up letters to non-responders will be mailed in mid-December.  To ensure that the maximum possible number of responses is obtained, Morpace will make telephone calls in January and February to those beneficiaries who still have not returned the survey.  The results will be reported to CMS in mid-February and used to calculate the ACO’s score in the seven-measure Patient/Caregiver Experience domain for 2015, the fourth year of the Pioneer ACO program.

If any of your patients receive the survey and ask you about it, please urge them to complete it.  

PY5 Montefiore Pioneer Model ACO Beneficiary Mailing

Newly attributed Medicare fee-for-service beneficiaries attributed to the Montefiore ACO will be notified in late December that their doctor is participating in the program.  There will be a toll-free number for them to call us with any questions about the ACO or how it works.  As soon as we get approval of the notification from CMS, we will send you a copy, along with FAQs for you and a second list that you can use to respond to questions from your patients.