Hi, I am confused about coding insulin along with oral anti diabetic medication. Are we supposed to code only insulin when both are listed? Or, if they are both listed, should we code both? The guidelines are confusing. I thought if both were documented, we only code insulin. Is this not the case? Please help!!
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Wiki Diabetic coding
- Thread starter suenzig
- Start date
mitchellde
True Blue
read the guidelines as updated for 2018. It states if controlled by both insulin and oral, code only the insulin.
mitchellde
True Blue
The excludes 2 note does not automatically mean you code both codes. the guidelines states:
3) Diabetes mellitus and the use of insulin and oral hypoglycemics
If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11-, Type 2 diabetes mellitus, should be assigned. An additional code should be assigned from category Z79 to identify the long-term (current) use of insulin or oral hypoglycemic drugs. If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin should be assigned. Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter.
This guidelines was effective for visit day on and after Oct 1 2017
3) Diabetes mellitus and the use of insulin and oral hypoglycemics
If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11-, Type 2 diabetes mellitus, should be assigned. An additional code should be assigned from category Z79 to identify the long-term (current) use of insulin or oral hypoglycemic drugs. If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin should be assigned. Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter.
This guidelines was effective for visit day on and after Oct 1 2017