Wiki Orthopedics - DM - Corticosteroids

[nolanspade]

Hello,

There is a disagreement about whether or not to code an underlying such as diabetes if the doctor mentions "watch your sugars with this steroid" in his note. It is not management per se, but it does affect the treatment and risk in MDM.

If the doctor writes "This diabetic patient was cautioned to monitor her glucose level closely after the injection" should diabetes then be coded in addition to OA? The mention is more than "per PCP."

 

[thomas7331]

In this example, the diabetes should be coded. Per the ICD-10 guidelines, section IV.J. you should code "all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management." It certainly meets the criteria in this case as it's clear that the diabetes poses an increased risk for the patient which the provider is addressing.