We are having a debate in my office on what needs to be documented when a patient has Diabetes and other conditions (ie: retinopathy or neuropathy) and doctor does not specify that the underlying condition is related to the Diabetes.
Some say you can assume the relation and code Diabetes with retinopathy. Others say you cannot assume if documentation does not use linking words (ie with, related to ) codes would need to either query doctor or code separately.
Can someone give some clarification?
Thank You
Christine
Some say you can assume the relation and code Diabetes with retinopathy. Others say you cannot assume if documentation does not use linking words (ie with, related to ) codes would need to either query doctor or code separately.
Can someone give some clarification?
Thank You
Christine