Wiki manifestation coding in diabetes

[john maceachern]

Hi I have documentation that is as below and I dont see how this meets the requirement of due to/with just because the neuropathy is listed under the diabetes. Where is the linkage? Would this be acceptable? Thanks John


Assessment and Plan
Diabetes with neurological manifestations-well controled/ Labs done today A1c 6.2
Peripheral Neuropathy- better on gabapentin

F/U in 1 month

 

[Cyndi113]

Unless the MD actually links them together, you can't use it as a manifestation.

 

[CarmonaEnterprises]

Hi John,
Check the documentation and with the provider chances are you can provided that it is confirmed either by the provider and previous visit notes from the patient's chart. Do the research before you code.
Jeff

 

[cordelia]

I am an inpatient coder and havent done professional coding for awhile, but isnt "diabetes with neurological manefestation" your link?

Cordelia, CCS, CPC

 

[Cyndi113]

Not according to the speaker we had last month. She's an HCC instructor with many years of experience. She says that unless the MD specifically states that the peripheral neuropathy IS the neurological mani, then you can't link it. I know it sounds crazy but they have to link it or it's just an assumption.

 

[mitchellde]

I think you are being too picky. The provider states the patient has neurological manifestations and then says the patient had peripheral neuropathy. This is very clear in my opinion . However having said that I never code from the impression I code from the exam note . What does the provider state within the body of the note. That is where the linkage must take place.