Wiki Diabetes Coding

[pamtienter]

When educating our providers in the clinic, we are telling them that uncontrolled diabetes won't be coded unless it's documented as uncontrolled. One doctor is saying that if the Hgb A1C is >8, it is obviously uncontrolled and should be able to be coded as such, even if she leaves out the word uncontrolled.

The ICD-9 Official Guidelines say "Effective October 1, 2008: Abnormal Findings- Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added. Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider."

Does this mean "uncontrolled" needs to be specified?

How are others coding these? Are you using the uncontrolled diabetes diagnosis codes even if they don't specify uncontrolled but have an A1C result?

Thanks for your help!

 

[Anna Weaver]

diabetes coding

I was taught not to code from lab results. These must be interpreted by a physician or other qualified clinician (NPP) and results documented in the medical record. Once those results are documented and signed by the physician, then and only then can we use them as a diagnosis. We may know from experience, and the results may certainly imply, what the patient's diagnosis is, but we can't code it until the Dr. says so.

 

[magnolia1]

We are coders, not Lab Technicians, Pathologists, or Physicians.
We are trained to code based on what is documented, not to interpret test results.

 

[mad_one80]

i agree with anna....dont code it as uncontrolled based on the path/lab results. let the doc know that you need her to document it and sign it for you to code it...after all, YOUR credentials are on the line!