Check Out the AACE/ACE 2016 Update on Standards of Medical Care in Diabetes

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Public health experts classify diabetes mellitus types 1 and 2 as major public health risks. In fact, according to the Centers for Disease Control (CDC), one out of every three Americans, or 86 million people, have prediabetes! With risks ranging from heart disease to limb loss and more, diabetes mellitus is a frightening disease that is preventable, but first at-risk patients must be found so they can be taught ways to avoid developing this disease.

AACE/ACE 2016 Update on Standards of Medical Care in Diabetes

The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) recently released new clinical practice guidelines for diagnosis and treatment of prediabetes and diabetes. These guidelines give clinicians clear cues that set into motion the tests that lead to diagnosis of prediabetes and diabetes, which means education and treatment can start sooner.

Screening Prediabetes and Type 2 Diabetes Mellitus

The AACE/ACE Comprehensive Type 2 diabetes guidelines for screening for prediabetes and type 2 diabetes mellitus in asymptomatic adults now include the following criteria that would trigger the provider to perform screening fasting glucose, hemoglobin A1c, and/or glucose tolerance tests.

  • Age 45 or older without other risk factors
  • Family history of type 2 diabetes
  • Personal history of cardiovascular disease
  • Overweight (specifically a BMI of greater than 30, or in the face of other risk factors, a BMI of 25 to 29.9)
  • Sedentary lifestyle
  • Member of an at-risk racial or ethnic group, including Asian, African American, Hispanic, Native American, and Pacific Islander
  • High cholesterol (dyslipidemia) with an HDL of less than 35 mg/dL and triglycerides of greater than 250 mg/dL
  • Impaired glucose tolerance, impaired fasting glucose, and/or metabolic syndrome
  • Diagnosis of polycystic ovary disease, acanthosis nigricans, or nonalcoholic fatty liver disease
  • Hypertension, defined as a blood pressure of 140/90 or greater, or requiring therapy for hypertension
  • History of gestational diabetes or delivery of a baby weighing more than 9 lb
  • Under antipsychotic therapy for schizophrenia and/or severe bipolar disease
  • Chronic glucocorticoid (steroid) exposure
  • Sleep disorders such as obstructive sleep apnea, sleep deprivation, and night shift occupations in the presence of glucose intolerance.

Getting the Diagnosis

Clinicians diagnose prediabetes, or being at high risk for diabetes, when patients’ fasting glucose is between 100 and 125 mg/dL, glucose tolerance test is 140 to 199 mg/dL, and hemoglobin A1c is 5.5 to 6.4%. The A1c test is usually done first and is mainly used for screening prediabetes. The diagnosis of prediabetes should be confirmed with glucose testing.

Clinicians look to confirm a diabetes mellitus diagnosis when patients’ hemoglobin A1c is greater than 6.5%. Values of glucose tolerance test of greater than 200 mg/dL and fasting blood glucose of 126 mg/dL confirm the diagnosis of mellitus diagnosis.

Coding for Prediabetes and Diabetes Prevention Education

You report the diagnosis for screening for diabetes mellitus with Z13.1 (Encounter for screening for diabetes mellitus). If the results come back elevated, you’d code the result. For example, if the A1c is less than 6.5% and the fasting glucose is between 96 and 126, you’d report R73.09 (Other abnormal glucose). Note that the alternative terminology for this code includes abnormal glucose NOS, abnormal non-fasting glucose tolerance, latent diabetes, and prediabetes. By the way, the preliminary list of ICD-10-CM 2017 codes indicates we’ll have a new code for prediabetes for DOS Oct. 1, 2016, and later. The new code will be R73.03 (Prediabetes). The list of 2017 ICD-10-CM codes is not yet final, but readers can catch an early peek at it at the CDC FTP site here.

If the patient’s A1c is greater than 6.5 and the glucose tolerance test and fasting blood glucose meet the above-listed parameters for diagnosis of diabetes mellitus, your provider will probably say the patient has overt diabetes. There are multiple ICD-10-CM coding options for diabetes mellitus, so your provider’s documentation will rule your choice here, but assuming there are no complications and no insulin use, you’d report E11 (Type 2 diabetes mellitus without complications). Note that E11 isn’t a code itself; reporting this requires additional characters.

New CPT® Category III Code for Diabetes Prevention

The concept of preventing diabetes is built into the Affordable Care Act, and CPT® 2016 embraced this new paradigm of delivery with a new Category III code for diabetes prevention. You’ll report 0403T (Preventive behavior change, intensive program of prevention of diabetes using a standardized diabetes prevention program curriculum, provided to individuals in a group setting, minimum 60 minutes, per day) for educational programs provided by nonphysician educators for situations where someone doesn’t have a diagnosis of the disease but has prediabetes or a propensity for developing diabetes. This prevention program can’t be used for people who already have diabetes, but rather for people at risk of developing this condition. According to the AMA, these educational efforts were given a Category III code to allow tracking of the courses’ success in preventing diabetes in at-risk populations. This procedure requires a standardized curriculum recognized by CDC, taught by community-based peer led groups.

How About You?

Have you had any personal or patient experience with diabetes prevention measures such as lifestyle changes and especially these new CDC-recognized courses? Let us know in the comment box below.

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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