Wiki HCC Coding DM uncontrolled in opthalmology office

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lisaaz74

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Hi Everyone!

Question for all you HCC coders.

I have an ophthalmology note where dr noted DM uncontrolled (2016 book guidelines) Pt is seen for diabetic eye exam. The coder added the E11.65. However, the client is saying this is an error because an ophthalmologist cannot code that because they would need the A1c. They also said that the "uncontrolled" can only be coded by a PCP type dr.

I would appreciate some feedback from those of you with experience, please. We have tried to explain to the client, the rules of the code book. If the physician documents it, you can code it--they are not budging.

Please help.

LA
 
From the coding guidelines:
19. Code assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

This does not mean a provider assigned code it means if there is a rendered diagnosis of uncontrolled diabetes then we will code it. The fact that the coder does not have access to an A1c level is not at issue. We do not question how a provider arrives at a diagnosis only that it has been rendered..
 
Different client has different guideline. As being a coder we should see the coding prospect not the clinical prospect. if a coder does not have the facility to query the provider then it is ok to code whatever is provider documentation. if a coder have the facility to query; its a good practice to query to provider for better documentation to code the correct specificity of any condition.

If Pt is seen for diabetic eye exam. an ophthalmologist can not control any diabetic eye complication without controlling DM. It simply mean ophthalmologist has to address DM aswell. So being a coder we can go with the provider documentation and code E11.65 .
 
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