We're having a discussion regarding uncontrolled diabetes. If the documentation only says history of uncontrolled diabetes and that the blood sugars are now running better at 150, do you still code the uncontrolled or controlled diabetes? I was under the impression that if the dr said uncontrolled (or complicated, for that matter) that they had to document the reason it's uncontrolled (or complicated). ie: uncontrolled with BS running 400 in am; complicated with renal htn, etc. I know we can't code from the lab results alone and that the dr has to state uncontrolled in order to code it, but just because the dr says it's uncontrolled, does that mean that's the only documentation we need to support that diagnosis? Thanks for all your help!
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