Wiki hyperglycemia and DM

[tolkita]

If Dr documents HYPERglycemia as diagnosis and according to the patients chart, patient has a history of DM - do you code 790.29 and 250.0x or just 250.0x?

Thanks

 

[ohn0disaster]

If the doctor documents Hyperglycemia, you code 790.29 ALONE, regardless of whether or not the patient's chart shows that they have a hx of DM. Every note stands alone.

I, personally, would go back to the doctor and bring it to their attention. If the doctor agrees to the dx of DM, he or she can correct this with an addendum to make the diagnosis as specific as possible.

 

[tolkita]

oh ok. so here's another situation.
what if the dr documents both hyperglycemia and DM as diagnosis? how do you code this?

 

[ohn0disaster]

If the doctor documents both DM and Hyperglycemia, only code DM, as coding the hyperglycemia would be redundant (and DM is the more specific dx).

BUT again, I'd go to the doc and ask if he meant that the patient's DM is not under control, which would make the code 250.02 (DM type 2 or unspecified, stated as uncontrolled), rather than 250.00 (DM type 2 or unspecified, not stated as uncontrolled).

 

[tolkita]

Thank you so much