rsb2918@aol.com
Contributor
Advice needed. Many EMR systems allow the providers to "pick" their diagnoses from a drop down list. Most providers know that diabetes is coded as E11.9 and will automatically grab this diagnosis, no matter what the complications are (we all know they are not coders and do not recognize the importance of documenting certain diagnoses together) . My issue is, that it will also populate the code with "Type 2 diabetes mellitus without complications". On a hand written chart, the provider will most likely document "diabetes" and the complications listed separately, where we can then assume the casual relationship between those listed under "with" in the index. My question is: Does the pre-populated statement of "without complications" negate the rule to casually assume a relationship between the other diagnoses in the record? My team has always made the casual relationship but have recently encountered a vendor who does not make this link. Any advice would be greatly appreciated.