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Wiki Hypoglycemia in Pre-Diabetes

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ginger43

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Patient has pre-diabetes, treated with metformin and presented to ER with an episode of hypoglycemia. Is this just coded as hypoglycemia, not related to diabetes along with the pre-diabetes code?
 
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Yes, if this is the only thing you have to go by, then I would just code the hypoglycemia and pre-diabetes and the Z79.84 for the metformin. You can't code the hypoglycemia as related to diabetes if the patient doesn't have that diagnosis.

My guess is that the hypoglycemia in this scenario would likely be an adverse effect of the metformin, but of course, you can't code that unless it is documented.
 
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Following on from Thomas' response regarding the Metformin and adverse effect. It could also be that the patient was not taking the meds as prescribed (in this case taking too much causing the blood sugar to drop too low), but again this would have to be clearly documented within the note.
 
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