Coding Diabetes with complications

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Lexington, NC
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In the assessment the provider has put type II diabetes with both eyes affected by proliferative retinopathy without macular edema, with long-term current use of insulin. Is that sufficient documentation for it to go out on the claim? The retinopathy is not talked about anywhere throughout the note. It is listed under the active problem list but no where else. I see a lot of providers who will give diabetes complication codes but do not say anything about the complication except listing it under the assessment. I feel like they should address it in some way. Please advise.
 

cpc4lib

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DM with bilat proliferative retinopathy w/out macular edema

Yes, that is enough. The patient provided medication/treatment (insulin). Sometimes, that particular provider (say a general practitioner) might not actually treat the retinopathy, but an ophthalmologist does. Provider currently seeing patient and stating "with" is enough to link the conditions to report as E11.353.
 

Chelle-Lynn

True Blue
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Modesto, CA
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If the providers list the description under the assessment as the full diagnosis then that is sufficient. Type II diabetes with bilateral proliferative retinopathy without macular edema, with long-term current use of insulin is a clear description of the final assessment of the patient by the provider. In a perfect world it would be good to show support for this diagnosis throughout the history and exam, but if this is an established patient that may not always be carried forward.
 
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