objective measures - What does it mean

Generally speaking, when we say 'objective measures,' what does that mean?

Answer: 

Objective measures consist of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome. Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment.

Reminder: Some forms, including the Oswestry, may not contain answers/responses that are objective (actual measures/values). The Chiropractor or patient may need to add additional information. For example, the form may use the term 'severe' for the evaluation of pain. 'Severe' is not an objective measure. The pain would need an specific value.

Examples of objective measures to evaluate goals include:

Pain
Baseline: 9 on a scale of 1-10
Goal: Decrease pain to 1
Standing:
Baseline: Only able to stand for 20 minutes
Goal: Able to stand for more than 1 hour
Range of Motion (ROM):
Baseline: Lumbar spine flexion of 53 degrees and extension 11 degrees
Goal: Increase lumbar flexion to 80 and extension to 25



Generally speaking, when we say a 'treatment plan with specific goals', what does that mean?

Answer:

Upon determination of a subluxation, the physician is required to develop an individualized treatment plan that includes the following:

Recommended level of care (duration and frequency of visits)
Specific treatment goals
Objective measures to evaluate treatment effectiveness
Objective measures consist of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome. Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment.

Some providers use forms (Oswestry, etc.) to measure treatment effectiveness. If this is the case, then a patient would need to complete the form on every visit.

Reminder: Some forms, including the Oswestry, may not contain answers/responses that are objective (actual measures/values). The Chiropractor or patient may need to add additional information. For example, the form may use the term 'severe' for the evaluation of pain. 'Severe' is not an objective measure. The pain would need a specific value.

Examples of objective measures to evaluate goals include:

Pain
Baseline: 9 on a scale of 1-10
Goal: Decrease pain to 1
Standing:
Baseline: Only able to stand for 20 minutes
Goal: Able to stand for more than 1 hour
Range of Motion (ROM):
Baseline: Lumbar spine flexion of 53 degrees and extension 11 degrees
Goal: Increase lumbar flexion to 80 and extension to 25


icd 10 code for allergic rhinitis - J30.1

Allergic rhinitis due to pollen 

J30.1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
   
This is the American ICD-10-CM version of J30.1. Other international versions of ICD-10 J30.1 may differ.
   
Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Information

   
Allergic rhinitis caused by outdoor allergens.
   
Allergic rhinitis that occurs at the same time every year. It is characterized by acute conjunctivitis with lacrimation and itching, and regarded as an allergic condition triggered by specific allergens.
   
Each spring, summer, and fall, trees, weeds and grasses release tiny pollen grains into the air. Some of the pollen ends up in your nose and throat. This can trigger a type of allergy called hay fever.symptoms can include

        sneezing, often with a runny or clogged nose
        coughing and postnasal drip
        itching eyes, nose and throat
        dark circles under the eyes
        taking medicines, using nasal sprays and rinsing out your nose can relieve symptoms.

Allergy shots can help make you less sensitive to pollen and provide long-term relief. Seasonal variety of allergic rhinitis, marked by acute conjunctivitis with lacrimation and itching; regarded as an allergic condition triggered by specific allergens.

Applicable To

    Allergy NOS due to pollen
    Hay fever
    Pollinosis

Approximate Synonyms

Allergic rhinitis (nose congestion), pollen

The following ICD-10-CM Index entries contain back-references to ICD-10-CM J30.1:

    Allergy, allergic (reaction) (to) T78.40
    due to pollen J30.1
    grain J30.1
    grass (hay fever) (pollen) J30.1
    nasal, seasonal due to pollen J30.1
    pollen (any) (hay fever) J30.1
    primrose J30.1
    primula J30.1
    ragweed (hay fever) (pollen) J30.1
    rose (pollen) J30.1
    Senecio jacobae (pollen) J30.1
    tree (any) (hay fever) (pollen) J30.1
    inhalant (rhinitis) J30.89
    pollen J30.1


J30 Vasomotor and allergic rhinitis Includes: spasmodic rhinorrhea Excludes: allergic rhinitis with asthma (bronchial) (J45.909) rhinitis NOS (J31.0) J30.0 Vasomotor rhinitis J30.1 Allergic rhinitis due to pollen Allergy NOS due to pollen Hay fever Pollinosis

SJ30.2 Other seasonal allergic rhinitis

SJ30.5 Allergic rhinitis due to food

SJ30.8 Other allergic rhinitis

SJ30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander

SJ30.89 Other allergic rhinitis

SPerennial allergic rhinitis

SJ30.9 Allergic rhinitis, unspecified

SJ31.0 Chronic rhinitis

SAtrophic rhinitis (chronic)

SGranulomatous rhinitis (chronic)

SHypertrophic rhinitis (chronic)

SObstructive rhinitis (chronic)

SOzena

SPurulent rhinitis (chronic)

SRhinitis (chronic) NOS

SUlcerative rhinitis (chronic)

SExcludes1: allergic rhinitis (J30.1-J30.9)

Svasomotor rhinitis (J30.0)

Includes: Allergic (predominantly) asthma Allergic bronchitis NOS Allergic rhinitis with asthma Atopic asthma Extrinsic allergic asthma Hay fever with asthma 
Idiosyncratic asthma Intrinsic nonallergic asthma Nonallergic asthma

SExcludes 1:

Sdetergent asthma (J69.8)

Seosinophilic asthma (J82)

Slung diseases due to external agents (J60-J70)

SMiner’s asthma (J60)

Swheezing NOS (R06.2) wood asthma (J67.8)

ICD- ALLERGIC DISORDERS

ICD-10CM

477.0

Allergic Rhinitis - pollen
J30.1

477.2

Allergic Rhinitis - danders
J30.81

477.8

Allergic Rhinitis - other
J30.89

477.1

Allergic Rhinitis - foods
J30.5

477.9

Allergic Rhinitis - unspecified
J30.9

372.05

Acute Atopic Conjunctivitis
H10.10- H10.13

372.00

Acute Conjunctivitis, unspecified eye
H10.30

Acute conjunctiviitis, unspecified rt eye
H10.31

Acute conjunctivitis, unspecified, left eye
H10.32

Acute conjunctivitis, unspecified, bilateral
H10.33

372.01

Acute Serous Conjunct-non viral
H10.231 thru H10.233

372.14

Chronic Allergic Conjunctivitis
H10.45

372.13

Seasonal conjunctivitis-childhood
H10.44

Simple chronic conjunctititis - right eye
H10.421

Simple chronic conjunctivitis - left eye
H10.422

Simple chronic conjunctivitis - bilateral
H10.423

Simple chronic conjunctivitis - unspecified eye
H10.429

381.04

OM acute allergic (mucoid) rt ear
H65.111

OM allergic acute & subacute lt ear
H65.112

OM allergic acute & subacute bilateral
H65.113

OM allergic recurrent rt ear
H65.114

OM allergic recurrent lt ear
H65.115

OM allergic recurrent bilateral
H65.116

OM allergic recurrent unspecified
H65.117

OM allergic and subacute unspecified
H65.119

381.1

OM Serous chronic, unspecified ear
H65.20

OM serous chronic, right ear
H65.21

OM Serous chronic, left ear
H65.22

OM Serous chronic, bilateral
H65.23

ICD-9CM

Skin Disorders

ICD-10CM

691.8

Atopic( neurodermatitis) Dermatitis
L20.81

Perioral Dermatitis
L71.0

692.84

Allergic eczema
L20.84

Contact , allergic due to adhesives
L23.1

692.8

Contact, allergic Dermatitis - animal
L23.81

692.0

Contact, allergy due to cosmetics
L23.2

692.3

Contact, allergy due to detergent
L23.89

692.5

Contact, allergy due to drugs (topical)
L23.3

692.4

Contact, allergy due to food
L23.6

692.83

Contact, allergy due to latex, rubber
L23.5

692.6

Contact, allergy due to metals
L23.0

Contact, allergy Due to plants
L23.7

Unspecified contact dermatitis, cosmetics
L25.0

Unspecified contact dermatitis, drugs
L25.1

Unspecified contact dermatitis, dyes
L25.2

Unspec contact dermatitis -other chemicals (cement, insecticide)
L25.3

Unspec contact dermatis food in contact
L25.4

Unspecified contact dermatitis due to plants
L25.5


For the practice of Allergy/Immunology, the conversion from ICD-9-CM to ICD-10-CM will be rather seamless for some diagnoses, and more complicated for others.

Asthma will be coded as intermittent or persistent, and add descriptors:

• Mild
• Moderate
• Severe

A fifth digit will be used to describe asthma as:
• Uncomplicated (x = 1)
• With exacerbation (x = 2)
• With status (x = 3).

FOOD PROTEIN0INDUCED ENTEROCOLITIS SYNDROME

K52.21 is a new, approved ICD-10 code for Food Protein-Induced Enterocolitis Syndrome FPIES is a non-IgE gastrointestinal food hypersensitivity that manifests as delayed, profuse vomiting, often with diarrhea, acute dehydration, and lethargy.

The most common triggers are milk and soy, but any food, even those thought to be hypoallergenic (e.g., rice and oat), can cause an FPIES reaction.

The new code is the result of advocacy efforts by the International Association for Food Protein Enterocolitis, a lay organization and partner of the AAAAI.

REPORTING DISEASES OF THE RESPIRATORY SYSTEM (J00-J99)

For the Respiratory disease, Chapter 10, the ICD-10 chapter instructions include the direction to use additional codes for describing the patient’s tobacco use, if documented in the patient’s medical record.

If the patient does not have a tobacco use, abuse, or dependence, no additional codes are required to describe your patient’s disease. For the patient who does use tobacco products and it is documented in their medical record, we must code not only their use but also describe the type of tobacco used.

The provider is directed to use only one code to describe the patient’s tobacco use. For example, if the patient uses and is dependent, you only assign the code for the dependence.

The provider must also select a sixth digit to describe if the patient’s dependence is as follows:

• 0 Uncomplicated
• 1 In remission
• 3 With withdrawal
• 8 With other nicotine-induced disorders
• 9 With unspecified nicotine-induced disorders

RESPIRATORY SYSTEM SCENARIOS

A patient presents with mild intermittent asthma who has smoked cigarettes in the past, but is not a current smoker. Your diagnosis codes would be J45.20 and Z87.891.

A patient presents with severe persistent asthma who is currently a long-time dependent cigarette smoker. Your diagnosis code would be J45.50 with F17.210.

A patient presents with moderate persistent asthma with no history of smoking or any use of tobacco products. Your correct diagnosis code(s) would be J45.40.

RHINITIS CODES

ICD-10 CM defines vasomotor rhinitis as a form of non-allergic rhinitis that is characterized by nasal congestion and posterior pharyngeal drainage.

J31.0 Chronic Rhinitis NOS description symptoms include:

• Rhinitis 
• Rhinitis (nasal congestion)
• Rhinitis (nasal congestion), chronic
• Rhinitis (nasal congestion), nonallergic
• Rhinitis due to alpha blocking medication
• Rhinitis due to alpha-adrenergic blocking agent
• Rhinitis medicamentosa

ICD 10 code for vitamin d deficiency E55.9

ICD10 code for Vitamin D deficiency

 E20.0 Idiopathic hypoparathyroidism
E20.8 Other hypoparathyroidism
E20.9 Hypoparathyroidism, unspecified
E21.0 -E21.3 Hyperparathyroidism and other disorders of parathyroid gland (code range)
E55.0 Rickets, active
E55.9 Vitamin D deficiency, unspecified
E83.3-83.9 Disorders of phosphorus metabolism (code range)
E83.51 Hypocalcemia
E83.52 Hypercalcemia
M81.0 Age-related osteoporosis without current pathological fracture
M81.6 Localized osteoporosis
M81.8 Other osteoporosis without current pathological fracture
M83.0-M83.9 Adult osteomalacia (code range)
M85.9 Disorder of bone density and structure, unspecified
N18.3-N18.5 Chronic kidney disease, Stage III to End stage renal disease (code range)
N25.81 Secondary hyperparathyroidism of renal origin

POLICY STATEMENT:

I. Based upon our criteria and assessment of the peer-reviewed literature, screening for Vitamin D deficiency in individuals considered high risk for vitamin D deficiency (See Policy Guideline I) is considered medically appropriate.

II. Based upon our criteria and assessment of the peer-reviewed literature, routine screening for Vitamin D deficiency in healthy adults or children is considered not medically necessary.

III. Based upon our criteria and assessment of the peer-reviewed literature, screening for Vitamin D deficiency for nonskeletal diseases (e.g., cardiovascular disease, cancer, and autoimmune disease) is considered not medically necessary.

POLICY GUIDELINES:

I. Individuals that are high risk for vitamin D deficiency include, but are not limited to:

A. Osteomalacia;
B. Osteoporosis;
C. Chronic kidney disease;
D. Hepatic failure;
E. Malabsorption syndromes (e.g., cystic fibrosis, inflammatory bowel disease, Crohn’s disease, bariatric surgery, radiation enteritis);
F. Hyperparathyroidism
G. Medications (e.g., antiseizure, glucocorticoids, AIDS medications, antifungals, cholestyramine);
H. African-American and Hispanic children and adults
I. Pregnant and lactating women;
J. Older adults (age greater than 65 years) with history of falls or nontraumatic fractures;
K. Obese children and adults (BMI greater than 30 kg/m2 );
L. Granuloma-forming disorders (e.g., sarcoidosis, tuberculosis, histoplamosis, coccidiomycosis, berylliosis);
M. Some lymphomas.

II. Serum concentration of 25 hydroxyvitamin D (25OHD) is the optimal clinical indicator of vitamin D metabolism due to the rapid conversion of vitamin D to 25 OHD with only a small fraction converted to 1,25 hydroxyvitamin D (1, 25 OHD).

III. The Federal Employee Health Benefit Program (FEHBP/FEP) requires that procedures, devices or laboratory tests approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational and thus these procedures, devices or laboratory tests may be assessed only on the basis of their medical necessity.
DESCRIPTION:

A major source of vitamin D for most humans comes from exposure of the skin to sunlight typically between 1000 hours and 1500 hours in the spring, summer, and fall. Vitamin D produced in the skin may last at least twice as long in the blood compared with ingested vitamin D. A variety of factors reduce the skin’s production of vitamin D3, including increased skin pigmentation, aging, and the topical application of a sunscreen. An alteration in the zenith angle of the sun caused by a change in latitude, season of the year, or time of day dramatically influences the skin’s production of  vitamin D3. Few foods naturally contain vitamin D2 or vitamin D3 however some foods have been fortified with Vitamin D.

Vitamin D deficiency results in abnormalities in calcium, phosphorus, and bone metabolism. Specifically, vitamin D deficiency causes a decrease in the efficiency of intestinal calcium and phosphorus absorption of dietary calcium and phosphorus, resulting in an increase in parathyroid hormone (PTH) levels. Secondary hyperparathyroidism maintains serum calcium in the normal range at the expense of mobilizing calcium from the skeleton and increasing phosphorus wasting in the kidneys. As a result there may be bone weakness and a generalized decrease in bone mineral density (BMD), resulting in osteopenia and osteoporosis. Vitamin D deficiency may also cause muscle weakness making standing and walking difficult for affected children. In the elderly, more frequent falls may occur, which increases their risk of fracture.

RATIONALE:

The Endocrine Society Task Force for Evaluation, Treatment and Prevention of Vitamin D deficiency (2011) recommended screening for vitamin D deficiency in individuals at risk for deficiency. The Task Force did not recommend population screening for vitamin D deficiency in individuals who are not at risk (high quality evidence).

High risk for vitamin D deficiency include those individuals with osteoporosis, chronic kidney failure, malabsoprtion syndromes, hyperparathyroidism, African-American and Hispanic children and adults, pregnant or lactating women, older adults with history of falls or non-traumatic fractures, obese children or adults (BMI greater than 30 kg/m2 ), granuloma-forming disorders, and some lymphomas.

The Agency for Healthcare Research and Quality report on Vitamin D and Calcium: a systematic review of health outcomes (2009) found that no qualified systematic reviews have evaluated the association between vitamin D intake or serum 25(OH)D concentrations and incidence of cardiovascular disease, body weight in adults, total cancer incidence and mortality, immune function-related outcomes, and pregnancy. There is fair evidence between low serum 25 (OH)D levels and rickets. However no threshold level has been determined when rickets will not occur. The association between low serum 25 (OH)D levels and the risk of falls, fractures or performance measures among postmenopausal women or elderly men is inconsistent. There is fair evidence to support an association between serum 25(OH)D and BMD or changes in BMD at the femoral neck in postmenopausal women and elderly men. However more recent studies show no significant effects of vitamin D supplementation on BMD in children or adults.

The Institute of Medicine (IOM) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium assessed the health outcomes associated with vitamin D and calcium (2010). The Committee found that the evidence supported a role for these nutrients in bone health but not in other health conditions. In addition, the Committee assigned an upper level to both vitamin D and calcium intake noting that beyond these levels the risk of harm increases. Too much calcium has been associated with kidney stone formation while very high levels of vitamin D are known to cause kidney and tissue damage.

The Institute for Clinical Systems Improvement (ICSI) Health Care Guidelines; Preventative Services for Adults recommendation states there is insufficient evidence to assess the balance of benefits and harms of counseling adults to get an adequate intake of vitamin D and calcium in order to prevent either cancer or bone fractures (Weak Recommendation). The evidence for effectiveness states that adequate calcium intake from food sources and supplements promote bone health; however, the evidence is insufficient to recommend counseling for noninstitutionalized, community-dwelling, asymptomatic adults without previous history of fractures or cancer. However, vitamin D supplementation does appear to be effective in preventing injury from falls in community-dwelling adults aged 65 years and over who are at increased risk for falls.

The U.S. Preventative Task Force (USPSTF) guidelines for Vitamin D and Calcium Supplementation to Prevent Fractures (2013) concluded that the current evidence is insufficient to assess the balance of the benefits and harms of combined vitamin D and calcium supplementation for the primary prevention of fractures in premenopausal women or in men (Grade I statement).

In addition the current evidence is insufficient to assess the balance of the benefits and harms of daily supplementation with greater than 400 IU of vitamin D3 and greater than 1,000 mg of calcium for the primary prevention of fractures in non-institutionalized postmenopausal women (Grade I statement). The USPSTF recommends against daily supplementation with 400 IU or less of vitamin D3 and 1,000 mg or less of calcium for the primary prevention of fractures in non-institutionalized postmenopausal women. (Grade: D Recommendation).

The U.S. Preventative Task Force (USPSTF) guidelines for Screening for Vitamin D deficiency in adults: U.S. Preventive Services Task Force Recommendation Statement (2015) found no studies that evaluated the direct benefit of screening for vitamin D deficiency in adults. The Task Force found adequate evidence that the harms of treatment of vitamin D deficiency are small to none. No studies reported on the harms of treatment of vitamin D deficiency or identified a significant increase in total adverse events, hypercalcemia, kidney stones, or gastrointestinal symptoms.
The Task Force found adequate evidence that treatment of asymptomatic vitamin D deficiency has no benefit on cancer, type 2 diabetes mellitus, risk for death in community-dwelling adults, and risk for fractures in persons not selected on the basis of being at high risk for fractures. The Task Force found inadequate evidence on the benefit of treatment of asymptomatic vitamin D deficiency on other outcomes, including psychosocial and physical functioning. Although the evidence is adequate for a few limited outcomes, the overall evidence on the early treatment of asymptomatic, screendetected  vitamin D deficiency in adults to improve overall health outcomes is inadequate.

The USPSTF concluded that the evidence on screening for vitamin D deficiency in community-dwelling, nonpregnant, asymptomatic adults aged 18 years or older to improve health outcomes is insufficient and that the balance of benefits and harms of screening and early intervention cannot be determined.

ICD9: 252.00-252.1 Disorders of the parathyroid gland (code range)

268.0 Rickets, active
268.2 Osteomalacia, unspecified
268.9 Unspecified vitamin D deficiency
275.3 Disorders of phosphorus metabolism
275.41 Hypocalcemia
275.42 Hypercalcemia
585.3-585.6 Chronic kidney disease, Stage III to End stage renal disease (code range)
588.81 Secondary hyperparathyroidism (of renal origin)
733.00 Osteoporosis, unspecified
733.01 Senile osteoporosis
733.02 Idiopathic osteoporosis
733.03 Disuse osteoporosis
733.09 Other, osteoporosis
733.90 Disorder of bone and cartilage, unspecified


ICD 10 code for peripheral vascular disease I73.9

ICD-10-CM PVD Diagnostic Codes 

I73.9 Peripheral vascular disease, unspecified

I73.89 Other specified peripheral vascular diseases

Diabetic Peripheral Angiopathy

E08.5­ Diabetes mellitus due to underlying condition w/diabetic peripheral angiopathy

E09.5­ Drug or chemical-induced diabetes mellitus w/
diabetic peripheral angiopathy

E10.5­ Type 1 diabetes mellitus w/diabetic peripheral angiopathy

E11.5­ Type 2 diabetes mellitus w/diabetic peripheral angiopathy

E13.5­ Other specified diabetes mellitus w/diabetic peripheral angiopathy Atherosclerosis of native arteries of the extremities

I70.20­ Unspecified Atherosclerosis of native arteries of extremities (-) Add 6th character:

I70.21­ Atherosclerosis of native arteries of extremities w/intermittent claudication

I70.22­ Atherosclerosis of native arteries of extremities w/rest pain

I70.26­ Atherosclerosis of native arteries of extremities w/gangrene

I70.29­ Other Atherosclerosis of native arteries of extremities

I70.23­ Atherosclerosis of native arteries of right leg w/ulceration (-) Add 6th character:

*Use add’l code to identify severity of ulcer (L97.-)

I70.24­ Atherosclerosis of native arteries of left leg w/ulceration

I70.25 Atherosclerosis of native arteries of other extremities w/ulceration Use add’l code to identify severity of ulcer (L98.49-)

Atherosclerosis of bypass graft of the extremities

I70.30­ Unspecified Atherosclerosis of unspec. type of bypass graft(s) of extremities

I70.31­ Atherosclerosis of unspec. type of bypass graft(s) of extremities w/intermittent claudication

I70.32­ Atherosclerosis of unspec. type of bypass graft(s) of extremities w/rest pain

I70.33­ Atherosclerosis of unspec. type of bypass graft(s) of right leg w/ulceration

Use add’l code to identify severity of ulcer (L97.-)

I70.34­ Atherosclerosis of unspec. type of bypass graft(s) of left leg w/ulceration

I70.35 Atherosclerosis of unspec. type of bypass graft(s) of other extremity w/ulceration Use add’l code to identify severity of ulcer (L98.49-)


Atherosclerosis of other types of bypass grafts of the extremities

I70.4­ Atherosclerosis of autologous vein bypass graft(s) of the extremities

(-) Additional characters:

See ICD-10-CM Code handbook for additional levels of specificity when assigning these codes

*Note the additional code assignment instructions

I70.5­ Atherosclerosis of non-autologous biological bypass graft(s) of the extremities

I70.6­ Atherosclerosis of non-biological bypass graft(s) of the extremities

I70.7­ Atherosclerosis of other type of bypass graft(s) of the extremities


PERIPHERAL ARTERY DISEASE (PAD) 

Provider’s guide to diagnose and code PAD

Peripheral Artery Disease (ICD-10 code I73.9) is estimated to affect 12 to 20% of Americans age 65 and older with as many as 75% of that group being asymptomatic (Rogers et al, 2011). Of note, for the purposes of this clinical flyer the term peripheral vascular disease (PVD) is used synonymously with PAD.

Who and how to screen for PAD

The updated 2013 American College of Cardiology and American Heart Association guidelines for the management of patients with PAD, recommends screening patients at risk for lower extremity PAD (Anderson et al, 2013).

The guidelines recommend reviewing vascular signs and symptoms (e.g., walking impairment, claudication, ischemic rest pain and/or presence of non-healing wounds) and physical examination (e.g., evaluation of pulses and inspection of lower extremities). The Trans-Atlantic Inter-Society Consensus Document on Management of PAD and U.S.

Preventative Task Force on screening for PAD identify similar screening criteria that address patient’s age, smoking history, co-morbid conditions and physical exam findings (Moyer, 2013 & Norgren et al, 2007).

The American College of Cardiology and American Heart Association guidelines further recommend obtaining an ankle-brachial index (ABI) if the patient has any of the following findings (Anderson et al., 2013):

› Exertional leg symptoms
› Non-healing wounds
› Age 65 years or older
› 50 years or older with a history of smoking or diabetes

If patient history or physical exam meets any one of the following criteria, assess if the patient can tolerate and will consent to an ABI procedure or equivalent device. Requirements to diagnose PAD

The ABI is a ratio of ankle and brachial systolic blood pressures. The resting ABI can establish the lower extremity PAD diagnosis in patients with symptoms or with significant risk factors (Anderson et al., 2013).

The American Cardiology and American Heart Association 2013 revised guidelines recommend the following interpretation for noncompression values for ABI (Anderson, 2013).

The diagnostic accuracy of the ABI can be hindered under the following conditions: (Ruff, 2003)

› Patient anxiety and/or discomfort

› Poor positioning of patient or restless patient

› Exam performed in a cold room

› Sphygmomanometer cuff wrong size for limb or improper use

Education, treatment, and follow up of abnormalfindings

Abnormal ABIs are diagnostic of PAD and can be associated with significant clinical findings and urgent diagnoses. When diagnosing PAD the clinician should consider additional testing if ABI indicates non-compressible vessels and additional complaints suggesting more severe/urgent pathology.

If patient is using tobacco/smoking, then educate the patient about the contribution of smoking to the risk of contracting PAD. This should include smoking cessation counseling/ materials. Encourage treatment and control of co-morbid chronic conditions like HTN, DM, hypercholesterolemia, and CAD. Encourage walking for exercise when not contraindicated.

Use of Aspirin or other similar anti-platelet medications may prevent the development of serious complications from PAD and associated atherosclerosis.

Coding and Documentation Guidelines

› Explicitly document findings to support diagnoses of PAD

› Document a diagnostic statement that is compatible with ICD-10-CM nomenclature

› Explicitly document treatment plan/follow-up

› Confirm face-to-face encounter is signed and dated by clinician. Include printed version of clinician’s full name and credentials (e.g., MD, DO, NP, PA)

› If the patient has diabetes mellitus (DM) code combination code to report DM with underlying associated Peripheral angiopathy with additional levels of specificity as:


Type 1
Type 2
Drug-induced
With gangrene
Without gangrene

› Atherosclerosis codes provide additional levels of specificity for:

Laterality

Right
Left
Bilateral

Ulcer site

› Status of artery and grafting material

Native
Bypass graft
Autologous
Non-autologous
 biological



ICD 10 CODE for Allergies - D69.0

DESCRIPTION

Allergy testing, evaluations, and immunotherapy are eligible for coverage according to the schedule of covered services in plan documents. Testing or treatment methods not considered as standard medical procedures are not eligible for coverage.

CODING INFORMATION

ICD-10 Codes that may support medical necessity:

D69.0 Allergic purpura

H10.401 – H10.409 Unspecified chronic conjunctivitis
H10.421 – H10.429 Simple chronic conjunctivitis
H10.44 Vernal conjunctivitis
H16.261 – H16.269 Vernal keratoconjunctivitis, with limbar and corneal
H10.411 – H10.419 Chronic giant papillary conjunctivitis
H10.45 Other chronic allergic conjunctivitis
H10.9 Unspecified conjunctivitis
J30.0 – J30.9 Vasomotor and allergic rhinitis
J31.0 – J31.2 Chronic rhinitis, nasopharyngitis and pharyngitis
J32.0 – J32.9 Chronic sinusitis
J33.0 – J33.9 Nasal polyp
J45.20 – J45.998 Asthma
K52.2 Allergic and dietetic gastroenteritis and colitis
K52.89 Other specified noninfective gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis, unspecified
L20.0 – L20.9 Atopic dermatitis
L22 Diaper dermatitis
L23.0 – L23.9 Allergic contact dermatitis
L24.0 – L24.9 Irritant contact dermatitis
L25.0 – L25.9 Unspecified contact dermatitis
L27.0 – L27.9 Dermatitis due to substances taken internally
L29.8 Other pruritus
L29.9 Pruritus, unspecified
L30.0 – L30.9 Other and unspecified dermatitis
L50.0 Allergic urticaria
L50.1 Idiopathic urticaria
L50.6 Contact urticaria
L50.8 Other urticaria
L50.9 Urticaria, unspecified
L56.4 Polymorphous light eruption
T50.905A-T50.905S Adverse effect of unspecified drugs, medicaments and biological substances
T50.995A-T50.905S Adverse effect of other drugs, medicaments and biological substances
T78.00xA-T78.1xxS Anaphylactic reaction due to food


ALLERGY TESTING / IMMUNOTHERAPY

POLICY/CRITERIA

A. The following allergy tests are covered benefits:

1. IgE Specific Antibody (e.g., RAST, micro-Elisa, immunocap) if clinically indicated for history of severe urticaria, hives, or severe allergy, when skin testing is inappropriate.

2. Skin tests (scratch, intradermal, pricks)

3. Patch application tests

4. Drug Provocation testing

5. Skin Endpoint Titration (SET). Skin endpoint titration is effective for quantifying patient sensitivity and for providing a safe starting dose for immunotherapy. SET has not been shown to be an effective guide to a final therapeutic dose.

B. The following services have not been proven to be effective in diagnosing and/or treating allergies, and are not covered benefits:

1. Cytotoxicity testing (Bryan's test)

2. Urine autoinjection (autogenous urine immunization)

3. Provocation testing and neutralization therapy for food allergy (intracutaneous, subcutaneous or sublingually). Also called Intracutaneous Progressive Dilution Food Test (IPDFT).

4. Antigen leukocyte cellular antibody test (ALCAT) for all indications including but not limited to testing for food allergies or intolerance (chemical sensitivities) and as a tool to establish elimination diets.

5. Electrodermal testing or electro-acupuncture*

6. Applied kinesiology or muscle strength testing of allergies

7. Reaginic pulse testing or pulse testing for allergies

8. Total serum immunoglobulin G (IgG), immunoglobulin A (IgA) and immunoglobulin M (IgM)

9. Testing of specific IgG antibody (e.g., by RAST or ELISA testing)

10. Lymphocyte subset counts

11. Lymphocyte function assay

12. Lymphocyte transformation test (LTT), also known as lymphocyte proliferation test and metal ion testing for metal-induced hypersensitivity response.

13. Cytokine, cytokine receptor assay and Th1/Th2 cytokine ratio

14. Natural Killer (NK) cell assay or activity

15. Food immune complex assay (FICA)

16. Leukocyte histamine release testing

17. Body chemical analysis

18. Sublingual immunotherapy (SLIT) as an alternative way to treat allergies without injections. SLIT is not FDA approved in the United States

*Note: Acupuncture may be covered with a rider for some commercial plans


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