Wiki Proper coding VS "diagnosing"?

[Suebenda1958]

I have been an LPN for 46 years and have read many, many progress notes, I read them "clinically" so when a Dr codes the PDX as E11.9 DM type 2 without complications but in the HPI it says DM type 2 with hyperglycemia and in the examination it says lipo-hypertrophy, I want to code it as uncontrolled DM type 2 with hyperglycemia E11.65 and code the lipo-hypertrophy E88.1? I have been "reminded" we are not to diagnosis, which I consider it as coding to the fullest extent. I would greatly appreciate any guidance on this. Thank you.

 

[Pam Warren]

In your current role as a coder, you have to remove your nursing cap and code that which the provider has documented. Now, the good news here is that in the HPI, the diagnosis is more specific, and although there's an urban legend that says coders can code only from the assessment and/or plan, that's not true. And as we all know, the diagnosis that populates the assessment/plan in most EHR notes is coming from a drop down list that's so extensive the provider doesn't have time to sort through it all. So.....a coder can code from any part of the note that the provider has signed off on. You could query the provider (and would do so in an inpatient facility instance), but the HPI calls out hyperglycemia, so I would code that. Often, unless the patient is in acute distress, providers will code 'without complications', not realizing that hyperglycemia is a coded complication. The instructional notes for coding for diabetes have the 'with' instructions, so IMO, you're good to code the more specific code.