Topic: Focus on documentation for new ICD-9-CM codes denoting secondary diabetes
HIM Connection, August 19, 2008
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Some of the code sets that were finalized for 2009 could present particularly difficult documentation requirements. For example, secondary diabetes (249.xx) might be a huge challenge to code, says Kathryn DeVault, RHIA, CCS, manager of professional practice resources at the American Health Information Management Association (AHIMA) in Chicago.
Provide coders with clinical education about secondary diabetes, and communicate to physicians the new secondary diabetes codes so they know what additional documentation they need to supply, DeVault says.
For example, patients with cystic fibrosis or malignant neoplasms can have secondary diabetes, so facilities need to strive for thoroughly documented medical histories and urge physicians to make connections in their notes between other conditions and secondary diabetes when appropriate, DeVault says.
"We need to look more carefully at the patient’s medication history," she says. "Coders can’t assume secondary diabetes just because something else such as Cushing’s disease or cystic fibrosis is present."
Physicians must specifically note the tie between another condition or medication and diabetes in their documentation so coders can assign the correct codes. Let’s say the physician documents "diabetes with chronic kidney disease." Even if the patient has a history of steroid use that may have caused secondary diabetes, without documentation that states this specific connection, coders should not assign secondary diabetes codes, DeVault says.
Editor’s note: This article is adapted from the August issue of Briefings on Coding Compliance Strategies. For more information, click here.
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