Wiki Coding Diabetic Retinopathy in Resolved Diabetes

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lgardner

lgardner

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hello fellow coders. :)

I need some input on coding diabetic retinopathy after the diabetes has resolved.

the patient's current a1c is 5.6 and the provider states that the diabetes was resolved due to weight loss, so he is not "controlled on medication", but the retinopathy still exists and is technically "due to diabetes".

can I code it with impaired fasting glucose (790.21), which is what the provider is assessing?
that just doesn't seem correct.

how about coding the retinopathy as background retinopathy, unspecified (362.10)?
I'm not sure that sounds right either, because (as I said above) the retinopathy was really "due to diabetes", but this is where I'm leaning.

I guess the same question goes for other diabetic manifestations, too (diabetic neuropathy, or angiopathy).

any input is greatly appreciated.

thanks.
 
If the diabetes is documented as having been due to obesity is hen it is secondary diabetes and should have been coded as such. Then if the retinopathy is documented as due to the diabetes then it is to be coded as diabetic retinopathy. So you would code the 249 as ell as the patient current weight status as overweight if documented as such. If the weight is normal the code the BMI and also the diabetic retinopathy. If the provider states technically retinopathy due to the diabetes then you will need to query to find out exactly what he means by that. Since the patient still has manifestations of the diabetes(maybe) then you will still need to code the diabetes. As a coder you cannot ascertain that this is background retinopathy. You need more clear documentation in my opinion
 
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the provider had never stated the diabetes was due to obesity.
he is now saying that it is resolved due to weight loss (as opposed to medication).

I am not the one to say that it is background retinopathy; the provider states "background diabetic retinopathy" in the note. I was wondering if the diabetes is now resolved if I should change it to non-diabetic "background retinopathy" code.
 
lgardner said:
the provider had never stated the diabetes was due to obesity.
he is now saying that it is resolved due to weight loss (as opposed to medication).

I am not the one to say that it is background retinopathy; the provider states "background diabetic retinopathy" in the note. I was wondering if the diabetes is now resolved if I should change it to non-diabetic "background retinopathy" code.
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if the retinopathy is due to the diabetes then it is still due to the diabetes. I really think you need to discuss this with the physician in more detail. if the patient was diagnosed diabetic and then suddenly they are not due to weight loss, then was it always secondary diabetes? he has chosen a very confusing way to document this condition.
 
DM linking term?

I know the linking terms to indicates a cause and effect relationship includes ?due to,? ?caused by,? ?with? and ?secondary to.? I wanted to ask before I have my providers change their wording. If a provider states " 2 DM uncontrolled complicated by neuropathy" if this word "complicated by " would show a cause and effect relationship?
 
In my years of of coding, I have learned that DM is never resolved. The patient will always have it and it is monitored by the physician for the rest of the pateint's life. In this case, it sounds like the patient's DM is controlled by diet which is a great thing. I am not a medical provider but I have been in this debate before and I have heard from physicians that DM is not resolved it is just controlled. So, in this case, I believe that the DM should still be coded but that is up to the physician of course. We can never make that decision. If the patient's glucose is still being monitored, then you would be able to code the DM. I guess I would ask, "what harm is done to still code the DM?" There is not an ICD-9 code for personal history of DM but there is one for personal history of endocrine disorder, V13.9. But, I would stay away from that code for DM if the patient is still being monitored.
 
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