Pulmonology Coding Alert

Question: If the patient has a chronic condition, such as diabetes, should I report that diagnosis even when the physician is not specifically treating it?

Arizona Subscriber

Answer: You would report the diabetes mellitus (DM) only if the physician noted that it was relevant to the patient's presentation.

For instance, if the patient presents with dyspnea and the physician places him on a course of steroids, the DM is clinically relevant because steroid use affects the patient's glycemic levels. You could report the diabetes as a chronic condition. If, however, a patient with asthma and DM presents with an asthma exacerbation but the chronic disease (diabetes) is not relevant to the present condition, do not report it separately.