Question Z79.4 &Z79.84

[mgrove58]

If a Provider sees a Diabetic patient and wants them to start on Insulin, do we still add the Z79.4 Long Term (current) use of Insulin? My co workers as well as myself have added this code to a few visits this week, and the Provider came back and said the patient hasn't been on this before and wanted us to remove it. We have looked everywhere to see what the guidelines are regarding this and came up with nothing. If anyone can help that would be great. Thank you

 

[thomas7331]

Remember that your ICD-10 codes are always assigned to report patient conditions that exist at the time of the encounter for which you are coding, based on the provider’s statement in the record. If the provider has not documented that patient was taking insulin at the time of the encounter, then it would not be correct to assign a code to report insulin use.

 

[TThivierge]

Mgrove
To add to what Thomas7331 is saying is true but sometimes patients get both injection and pills to treat a DM illness. But you would code only the injectable dx Z79.4 not the oral Z79.84 if pt received both. But it should be documented long term insulin.
Lady T