Wiki Major Diabetes complication confusion!!!

[robrien12]

I am dealing with a lot of debate about when it is ok to code a complication with Diabetes. This is creating A LOT of contention between the providers and coders.

Example:
Pt comes in for possible Strep. In the HPI it states the Blood sugars are in the 300's and they have DMII with complications: Peripheral neuropathy.
Nothing in the Assessment or plan talks about the DMII issues, the provider has E11.65 for the DMII hyperglycemia. Would you or would you not code for the DMII complication E11.40 as well??

Any help to clarify this would be most helpful.

 

[mitchellde]

The general rule of thumb is you code those conditions that are managed controlled or treated or that complicated the plan of care for the presenting condition. However there must be some documentation of this. So we're the meds adjusted, or anything along those lines. If it is just a statement in the history and nothing else then no it should not be coded.