Wiki EMR: "diabetes without complications" documented with diagnoses listed under "with"

[rsb2918@aol.com]

Advice needed. Many EMR systems allow the providers to "pick" their diagnoses from a drop down list. Most providers know that diabetes is coded as E11.9 and will automatically grab this diagnosis, no matter what the complications are (we all know they are not coders and do not recognize the importance of documenting certain diagnoses together) . My issue is, that it will also populate the code with "Type 2 diabetes mellitus without complications". On a hand written chart, the provider will most likely document "diabetes" and the complications listed separately, where we can then assume the casual relationship between those listed under "with" in the index. My question is: Does the pre-populated statement of "without complications" negate the rule to casually assume a relationship between the other diagnoses in the record? My team has always made the casual relationship but have recently encountered a vendor who does not make this link. Any advice would be greatly appreciated.

 

[thomas7331]

A minor note - it's 'causal' relationship, not 'casual' relationship.

That aside, you say that the drop down list allows the provider to pick a diagnosis - are they picking an actual diagnosis, or are they picking a code and the code descriptor is then populating as a the diagnosis? These are two different things. If the drop down is the actual diagnosis, then 'without complications' means just that, the diabetes has no complications, so you would not link the other conditions. However, if the EMR is populating the code descriptor, then "Type 2 diabetes mellitus without complications" is a descriptor for E11.9 which includes a number of different potential diagnoses, including 'Type 2 diabetes mellitus without complications' and 'Type 2 diabetes' as well as just 'diabetes', and technically you would need to query the provider for clarification because they haven't really given a diagnosis if they're just giving you a code.

I guess my first thought would be you need to talk to your providers. If they don't understand coding, they shouldn't be picking codes. And they shouldn't be using code descriptors to document a diagnosis - the diagnosis needs to be in their own words, not in the words assigned to an ICD-10 code. Based on the outcome of your discussion, and knowing what the providers' intent is here, then you can decide what is really the most appropriate way to handle the coding challenge.

My personal approach has been that if I see a provider just picking from code lists, I assume they're doing just that, and I will not presume anything to be one way or the other and won't assign that code unless it's supported in the rest of the record as well. Hope that may help some?