Wiki primary vs. secondary DM II

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BrenLea14

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I'm coding a case where the patient has sarcoidosis and DM II. She was diagnosed with sarcoid in April of 2010. She was diagnosed with DM II in Nov. of 2010. In her most recent hospital stay (October 2014), the provider lists "Steroid-induced DM." In all the years up to this point, previous coders have used the primary DM II code. During her recent stay, I used the secondary DM code. The billing manager is concerned that this is a discrepancy that will raise a flag to Medicare. I believe her initial Dx of DM II was steroid-induced, but it was not documented as such. What is the best way to approach this?

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Brenda
 
Keyword, that you used yourself, is DOCUMENTED. if it's not documented as secondary then it's not secondary. It has to be coded to the documentation provided. Coders don't and can't direct documentation other than to ask for more from the provider.
 
Steroid induced is secondary and if documented that way you must code it using the 249 and the E code for adverse reaction... It is unfortunate that the previous coders did not query for clarification... But the encounter you have is clear and must be coded the way it is documented.
 
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