Health Information Management

Straight talk about uncontrolled diabetes

Briefings on Coding Compliance Strategies, April 1, 2009

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We’ve been in the medical record documentation business a long time, and we’ve heard many horror stories about consultants who offer inaccurate, unethical, or irresponsible advice about uncontrolled diabetes. For example, say a diabetic patient with pneumonia presents to the hospital. The patient’s pneumonia, however, does not affect DRG assignment because it is not a complication and comorbidity (CC) or a major CC.

Physicians should strive to describe the patient’s true condition, complexity, and severity in words that a coder can then translate into the ICD-9-CM code that best matches the diseases. This practice has nothing to do with Medicare.

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