Wiki Diabetes with multiple complications

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sorcha48

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If the patient has diabetes with neuropathy and retinopathy, should each complication be coded separately? I have a patient seen for uncontrolled diabetes. Neither of the complications were addressed.
 
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I am not an expert. Here are my thoughts: yes, I would code diabetes with neuropathy and diabetes with retinopathy because pt was seen for diabetes and you are describing what kind of diabetes, what other body parts the diabetes affected. In our case it's neuropathy and retinopathy. There is also a separate code for 'uncontrolled' diabetes. We tell a full story.
 
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If there's no MEAT (Monitor, Evaluate, Assess, Treat), the problem was not addressed during the visit, and should not be coded.

"Coding professionals should not assign codes based solely on diagnoses noted in the history, problem list and/or a medication list. It is the provider’s responsibility to document that the chronic condition affected care and management of the patient for that encounter." --AHA Coding Clinic Q3 2021

If any treatment was directed at either condition, then yes, code them separately. Documenting there was no treatement is considered addressing ("neuropathy stable, continue to monitor.") Indicating they are being managed by another provider is considered addressing ("retinopathy improving, followed by Dr. Smith at Earl's Eyecare-o-Rama.")
 
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