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Diabetes uncontrolled documentation

  1. #1
    Default Diabetes uncontrolled documentation
    Medical Coding Books
    "Sub optimally controlled" is it acceptable medical term to code DM uncontrolled?

    Is there any guidelines to show to the physicians how to document properly for Uncontrolled DM? Physicians most of the time write FBS# or A1C # s for DM codes.

    Thank you

  2. #2
    No, query the physician for unclear documentation, if possible.


    Uncontrolled diabetes should not be coded unless the physician's documentation indicates that the diabetes is uncontrolled or out of control. You cannot assume that poorly controlled diabetes means uncontrolled without additional documentation from the physician. If the documentation is unclear, query the physician as to whether or not the patient's diabetes is uncontrolled.

    If the physician documents “poorly controlled” diabetes, query the physician as to whether he or she is stating that the patient’s diabetes is uncontrolled. It cannot be assumed that “poorly controlled” diabetes means “uncontrolled” without additional documentation from the physician (AHA Coding Clinic for ICD-9-CM, 2002, second quarter, page 13).

  3. #3
    Thank you for your feed back.

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