Wiki Coding Hyperglycemia & DM

[calicoder10]

I am new to coding (3 months) and code only ED charts.

My question is, if a patient with a history of DM 2,comes in to the ED and the MD only reports hyperglycemia as the final dx, do I report it as just hyperglycemia (790.29) or DM 2 w/o complications (250.00)?

There is no mention of DM out of controlled or uncontrolled.

Thanks,
deniseb

 

[mitchellde]

You cannot code the 790 with the 250 codes as they are excluded. If duabetes is not documented on the encounter and you are getting that from an older note then you cannot code it at all just code the 790.29. If the diabetes is documented on this note then you will need to query the physician as both codes cannot be coded together.

 

[calicoder10]

Thanks for your help!