warrenfamily103@gmail.com
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Hello everyone,
I am hoping to get some advice on a coding scenario I have. We are on paper charts so things can get a little tricky at times, especially with the notes we are currently using... on our note, Diabetes is one of the printed diagnoses and it looks like this- DM II (with/without) complications. The provider circled without complications. On another area of the note he put CKD-2. Per coding guidelines, the word "with" or "in" should be interpreted to mean "associated with" or "due to" when it appears in a code title in the Alphabetic index and there doesn't need specific documentation linking the two unless the provider specifically stated they weren't related. With this said, by him circling "without complications" on the note, does that mean that the CKD is not sue to the Diabetes. I will definitely try to query him, but in case I am unable, would this code as E11.9 (DM without complications) and N18.2 (CKD stage 2) or E11.22 (Diabetes with CKD) and N18.2 (CKD stage2)? The A1c was 5.7 so I am thinking he circled without complications for that reason, not being aware of the coding guidelines.
I am hoping to get some advice on a coding scenario I have. We are on paper charts so things can get a little tricky at times, especially with the notes we are currently using... on our note, Diabetes is one of the printed diagnoses and it looks like this- DM II (with/without) complications. The provider circled without complications. On another area of the note he put CKD-2. Per coding guidelines, the word "with" or "in" should be interpreted to mean "associated with" or "due to" when it appears in a code title in the Alphabetic index and there doesn't need specific documentation linking the two unless the provider specifically stated they weren't related. With this said, by him circling "without complications" on the note, does that mean that the CKD is not sue to the Diabetes. I will definitely try to query him, but in case I am unable, would this code as E11.9 (DM without complications) and N18.2 (CKD stage 2) or E11.22 (Diabetes with CKD) and N18.2 (CKD stage2)? The A1c was 5.7 so I am thinking he circled without complications for that reason, not being aware of the coding guidelines.