DM Type 2 patient with surgically treated cataracts

proucken

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Since Diabetes with cataracts is considered a causal link in the absence of provider documentation, if the diabetic patient has had surgery to correct the cataract is it to right to assume the condition has resolved and coding the E11.36 would no longer be appropriate?
 

Pathos

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This really depends on the documentation. If the cataract is considered repaired or fixed and this is reflected in documentation, then that condition is no longer active. I would not make the casual link at that point. Similarly, if a diabetic ulcer is healed, you would no longer make the casual link with DM and ulcer.
 

thomas7331

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I agree with Pathos - this must depend on the documentation. Per the guidelines "assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists." The provider must have documented that the cataract exists at the current encounter in order to be able to make that code assignment.
 
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