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Note reads! Patient presents weak and tired since this morning, very thirsty, dry mouth. Glucose in office 68, hypoglycemic. Does not check glucose at home and does not adhere to diabetic diet. Diabetes with good control on oral meds. Complications of ckd3 A1C 6.5 How would you code this?
 

mitchellde

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the important question is how would you code this. The provider tells you the patient is diabetic, on oral meds, has hypoglycemia and CKD3. That is all you need. Use your coding guidelines and your codebook and you will get the correct codes Post your answer here, if you choose poorly I or someone else will set you back to the correct path. If we give you the codes you will not learn for the future.
 
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Diabetes

Debra,

Myself would could this as E11.649, E11.22, N18.3 and Z79.84. My reason for the inquiry is the doctor coded this as E11.29 and R53.81. In my opinion the R53.81 would not be coded as I feel this would be a symptom of the Hypoglycemic episode. the patient presented with hypoglycemia so this would be my first listed diagnosis not DM with renal complications. I also feel his documentation contradicts the patients state of health as he stated in the note Diabetes with "good control" on oral meds were is the good control or am I missing something. Also his use of E11.29 instead of E11.22 which would be more specific to the patients state of health.


Am I correct?

Another example:

DM2 currently on Humalog via insulin pump. Following with Dr. Diabetes, Next appt 5-10-19. Last A1C 9.8. She tries to watch her diet. A/P states under DM dx will be adding Trulicity and Ozempic and discuss further diabetic control.

I would like to code as E11.65. My decision is purely based off that the patient is on an insulin pump and that the patients endocrinologist is to add two new medications which to me indicates not controlled but since they have not documented any complications I feel it would be best to code as follows.

Codes I would use E11.9, Z79.4, Z96.41

Am I correct?
 
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mitchellde

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yes I agree with your choices, they match the documentation. You would not code the fatigue unless the provider documents this as an unrelated symptom requiring further investigation. Also on the second example.. while you feel this may be Diabetes with hyperglycemia it is not up to the coder to diagnose this based on treatment. I have had known diabetics to be on insulin pumps and they were not hyperglycemic. So even though you wanted to code it as such your ultimate choice of codes I agree with.
Also I agree that the first scenario is a little contradictory as to the good control. but it does not affect the code choices.
 
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