Health Information Management

PPV: Pay attention to details when documenting diabetes

HIM-HIPAA Insider, April 10, 2007

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We are learning that our documentation in the medical record in the office, nursing home, and hospital leads to information that determines the quality of--as well as the reimbursement for--the care we deliver. Whether talking about mortality rates or pay for performance, the more accurately we portray what we think, what we conclude, and what we're going to do about it, the better we look--and the better the organization can defend its medical records against folks who might question it.

What disease are we talking about?

The term "diabetes" can lead someone down multiple paths. The term itself means increased urine output. Well, that can happen because of many etiologies, not only diabetes. So, we have to clarify whether the diabetes we're talking about is diabetes mellitus, diabetes insipidus, or another disease process altogether.

The ADA has released its recommended classifications of the major forms of diabetes. Basically, there are four major divisions, as follows:

  • Type 1 diabetes mellitus
  • Type 2 diabetes mellitus (what we may sometimes call type one and a half will fit into this category)
  • Other secondary causes of diabetes
  • Gestational diabetes
  • To read more about documenting diabetes, click here. Subscribers to Medical Records Briefing can sign-on for access.

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