Wiki DM w/manifestations

[rckesterson1]

250.52 is used in office note for the first time on 7/14/15- all previous visits have 250.02 back to 10/2011- There is no mention of the patient having retinopathy by the provider in this note or any previous note by the same provider. When asked to change the code and/or documentation because of the above the providers response: "see the opthalmalogy consult note from 4/12/13"

It does state that the patient has mild retinopathy; however, does this count as siting the opthalmic manifestation? My understanding is that it needs to be documented in the note that the issue is being assessed?

 

[thomas7331]

The code should reflect what is written in the documentation. Often, providers will choose codes to diagnose the patient, so the code may be accurate to the patient's condition, but if they have not documented that they are diagnosing the patient with that condition, then the code is not the correct choice for coding that note.

 

[mitchellde]

You cannot use diagnosis from other providers nites. In addition the retinopathy must be directly linked to the DM as th causal factor.