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Current DM vs. Hx - Risk Adjustment

  1. #1
    Location
    Eugene, OR Chapter
    Posts
    15
    Default Current DM vs. Hx - Risk Adjustment
    Medical Coding Books
    This is from a Risk Adjustment Comprehensive Health Evaluation, where HCC relevant dx codes will be submitted to CMS for Risk Adjustment reimbursement.

    Note states “Her LDL is above 100. She does not have active DM, loosing (sic) weight when first diagnosed and has had no HGA1c above 6.5.”

    Current BMI: 25.1

    Problems list states “Niddm dm-2 uncomplicated (250.00) Onset: 08/20/2008”

    PMH states “Last reviewed Past Medical History 03/17/2011
    Diabetes: Y – type II
    Heart / Vascular Disease: Y – CAD, Myocardial Infraction (sic)
    High Blood Pressure: Y
    High Cholesterol: Y”

    Not currently on any medication for DM, or insulin; no known family hx of DM.

    Current dxs of CAD, hyperlipidemia, HTN, and old MI.

    Note goes on to state “…(250.00) – Was diagnosed in 2003 by Dr. ___. Patient lost a significant amount of weight and has not had Hga1c out of range since.
    Lipid panel – Note to lab: Fasting
    Hemoglobin A1c
    Comprehensive metabolic panel”

    I recommended that since 250.00 is described as not active and pt hasn't had A1C out of range since significant weight loss, that the code should be removed or replaced with: Personal history of other endocrine, metabolic, and immunity disorders (V12.2).

    Provider followed up with “She still is considered to have DM but controlled with TLC.”

    I know my recommendation may be wrong, but I am just getting more conflicted with every piece of guidance I read. What do other coders think – would you consider the pt to have a current dx of DM, but controlled with lifestyle changes? Or pt has a hx of DM? Or something else?

    Thank you for any advice!
    Jasmine Stone, CPC-P | Risk Adjustment QA Coder
    ATRIO Health Plans
    Roseburg, OR

    atriohp.com

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by jasmine.stone View Post
    This is from a Risk Adjustment Comprehensive Health Evaluation, where HCC relevant dx codes will be submitted to CMS for Risk Adjustment reimbursement.

    Note states “Her LDL is above 100. She does not have active DM, loosing (sic) weight when first diagnosed and has had no HGA1c above 6.5.”

    Current BMI: 25.1

    Problems list states “Niddm dm-2 uncomplicated (250.00) Onset: 08/20/2008”

    PMH states “Last reviewed Past Medical History 03/17/2011
    Diabetes: Y – type II
    Heart / Vascular Disease: Y – CAD, Myocardial Infraction (sic)
    High Blood Pressure: Y
    High Cholesterol: Y”

    Not currently on any medication for DM, or insulin; no known family hx of DM.

    Current dxs of CAD, hyperlipidemia, HTN, and old MI.

    Note goes on to state “…(250.00) – Was diagnosed in 2003 by Dr. ___. Patient lost a significant amount of weight and has not had Hga1c out of range since.
    Lipid panel – Note to lab: Fasting
    Hemoglobin A1c
    Comprehensive metabolic panel”

    I recommended that since 250.00 is described as not active and pt hasn't had A1C out of range since significant weight loss, that the code should be removed or replaced with: Personal history of other endocrine, metabolic, and immunity disorders (V12.2).

    Provider followed up with “She still is considered to have DM but controlled with TLC.”

    I know my recommendation may be wrong, but I am just getting more conflicted with every piece of guidance I read. What do other coders think – would you consider the pt to have a current dx of DM, but controlled with lifestyle changes? Or pt has a hx of DM? Or something else?

    Thank you for any advice!
    I think you have to go with what the provider has stated. The patient is still considered to have Type II Diabetes Mellitus, but it is enviromentally controlled. She is not cured, if her lifestyle changes are dropped she could quite reasonably returned to uncontrolled Type II DM and potentially need medication. If at some point in the future, the provider chooses to change the patient's status to History of endocrine disorder, then you could change the diagnosis code.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #3
    Default DM
    I will code DM 250.00 in your case.
    As long as the provider documented DM with words like "well-controlled / managed by diet, life style change.....etc.
    There are a lot of chronic conditions that the patient is asymptomatic, either on med or not, but the conditions still exist. Such as DM, CHF, etc. The key relies on how providers document them

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