Sizing up insulin resistance—one treatment doesn’t fit all
There is no single best intervention for all women. It depends on the severity of glucose intolerance and metabolic abnormality in each patient.
Although Suzanne has a history of hirsutism, and occasionally plucks chest hair, she has been satisfied with her response to the OC. She has no other medical problems and does not smoke. Although she has a strong family history of type 2 diabetes, with both parents now on oral agents, there is no family history of premature heart disease.
She is 5 ft 9 inches tall and weighs 200 lb, with a body mass index of 29.5 kg/m2 (a BMI of 25 to 30 is overweight). Her blood pressure is 110 mm Hg systolic, 70 mm Hg diastolic, and her waist circumference is 90 cm. She has mild hirsutism. Other physical examination findings, including breast and pelvic examinations, are normal.
A fasting lipid profile reveals that Suzanne’s HDL cholesterol is 55 mg/dL, triglycerides are 175 mg/dL, and total and low-density lipoprotein (LDL) cholesterol are normal. A modified oral glucose tolerance test (OGTT) shows a fasting glucose level of 95 mg/dL and a 2-hour glucose level of 180 mg/dL, consistent with IGT.
Diagnostic phase. Polycystic ovary syndrome (PCOS) signs and symptoms are reported as such until you identify PCOS. For example, if the patient has excessive body hair, use hirsutism code ICD-9-CM 704.1; for obesity, code for unspecified obesity (278.00), morbid or severe obesity (278.01), or obesity of endocrine origin (259.9). If she has irregular menstrual periods, use the code for that condition (626.4).
Use the code for polycystic ovaries and PCOS (ICD-9-CM 256.4) once you have a diagnosis, during management, or when additional metabolic studies are done to rule out coexisting problems.
Link tests to suspected condition. A battery of laboratory tests will usually be part of diagnosis. Because many payers do not reimburse for routine screening tests, it is important to indicate that these tests are being performed to diagnose a suspected condition.
When screening women for metabolic syndrome and glucose intolerance, you may consider:
- Lipid panel (CPT 80061), linked to a diagnosis of obesity or a family history of cardiovascular disease (V17.4).
- Diabetes screening (CPT 82947 for fasting glucose plus 82950 for the 2-hour post glucose specimen) linked to a history of gestational diabetes (V13.29, other genital system and obstetric disorders) or family history of diabetes (V18.0), and possibly obesity.
After diagnosis, use E/M codes. Once you confirm PCOS and determine that management of affected systems is required, most follow-up care will be reported using evaluation and management (E/M) codes (99212–99215 for the established patient). Also use the E/M codes for initial physician encounters for diagnosis: consultation codes if another provider sends the patient to you for evaluation, or new/established patient codes if not.
Document counseling time. Some visits may entail counseling, so it is important to document counseling time (as well as total face-to-face time) with the patient. This allows you to select the E/M code based on total time, rather than on 2 of the 3 key components of history, examination, and/or medical decision-making.
The linking diagnosis during the management phase will be PCOS (256.4), along with any supporting diagnosis related to coexisting problems being managed at the time of the visit.
—Melanie Witt, RN, CPC, MA
Consider overall risk, modifiable factors
Besides the IGT, this patient has other risk factors for diabetes, including her BMI, strong family history, and several stigmata of metabolic syndrome, although she does not meet the ATP-III criteria for the syndrome. Nevertheless, the IGT merits attention.
While small case series suggest OCs can worsen glucose tolerance in women with PCOS, the overall evidence is conflicting. The Nurses Health Study16 found no association between type 2 diabetes and OC use.
One treatment option would be to discontinue the OC and see whether glucose tolerance normalizes, but Suzanne expresses a desire to continue the OC, given her overall satisfaction with its contraceptive benefit and control of hirsutism. Another factor to consider is the profound lifetime benefit OCs offer in protection against endometrial cancer.
I recommend a structured lifestyle intervention and would refer her to an exercise physiologist and dietician, because I am concerned about her other risk factors for diabetes, including her weight and strong family history.
When to add metformin
This patient also may benefit from concomitant use of metformin. Although we lack evidence that the combination of intensive lifestyle intervention and metformin is superior to lifestyle intervention alone, there is suggestive evidence from a small pilot clinical trial in women with PCOS.17
In Suzanne’s case I would treat the IGT more aggressively, given her strong family history of diabetes and her overweight status, by recommending that she add metformin to her regimen.
