Wiki How to code diagnosis diabetes mellitus with A1C

[anne.l.pedigo@gmail.com]

I have had 2 different doctors in the past week list their patient's elevated A1C with the diabetes diagnosis. Listed in the Assessment, the doctor wrote as the patient's diagnosis "Diabetes Mellitus, Type II with A1C 8.7". For the 2nd doctor, he wrote the unforgivable..."Uncontrolled diabetes, A1C, 7.6". I understand that we cannot code from lab values but both doctors are clearly trying to express the patients have DM with hyperglycemia. In both H&Ps, the doctors discuss the patients needing to watch their diets, loose weight, etc, etc. So what should I code these as? E11.65 or E11.9?

 

[Chelle-Lynn]

In our office unless the provider specifically states hyperglycemia or provides clear documentation, we would code at E11.9. Like you said, the lab test is not enough to assume this distinction, nor is the counseling on diet.

I would however, use this as an opportunity to discuss the documentation with the provider so that they are aware of what is needed for coding hyperglycemia if that is what they are intending.

 

[anne.l.pedigo@gmail.com]

What would you consider clear documentation?

 

[Chelle-Lynn]

For example:

"reviewed A1C 8.7 results with the patient inconjunction with her documented daily glucose spikes of between 200-300 and discussed the need to control these numbers via medication, diet, and exercise....."