Ask the expert: If an emergency department patient is a known diabetic (we don't know which type), and the physician's dictation states in the medication list that the patient is on Humulin and did not receive any during this encounter, can we use V58.67?
HIM-HIPAA Insider, May 8, 2007
Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!
A: Presumably, yes, based on the fact that the patient's treatment regimen is to receive Humulin to treat the diabetes, regardless of type. The code is for long-term (current) use of insulin-V58.67. However, be careful not to confuse a list of medications the patient takes regularly with the medication administration record (MAR). The MAR does not always necessarily mirror what the patient generally takes outside the hospital. For example, patients can be on Glucophage as their daily treatment regimen but might receive Humulin temporarily to treat insulin levels while in the hospital (inpatient/outpatient).
However, upon discharge, the patients will resume their normal treatment regimen of Glucophage. The MAR states only what was administered during the admission/ encounter. There is a difference between a physician identifying the list of medications a patient currently takes and the MAR for an admission/encounter.
Shannon McCall, RHIA, CCS, CPC, director of coding and HIM for HCPro, Inc., in Glen Allen, VA, answered the previous question. To read more click here.
Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!
Related Products
-
Briefings on APCs
Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...
-
HIM Briefings
Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...
-
Briefings on Coding Compliance Strategies
Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...
-
Briefings on HIPAA
How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...
-
APCs Insider
This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...
Most Popular
- Articles
-
- CMS puts hospital surveys on limited hold as surge continues
- Don't forget the three checks in medication administration
- Practice the six rights of medication administration
- Note similarities and differences between HCPCS, CPT® codes
- Q&A: Primary, principal, and secondary diagnoses
- The consequences of an incomplete medical record
- Nursing responsibilities for managing pain
- Skills of effective case managers
- ICD-10-CM coma, stroke codes require more specific documentation
- OB services: Coding inside and outside of the package
- E-mailed
-
- CMS puts hospital surveys on limited hold as surge continues
- Charge and bill Medicare all pre-operative diagnostic tests
- How to create a safety protocol for emergency department psychiatric patients
- Know guidelines and subtle differences in code descriptions for laceration repairs
- Q&A: Mechanical room storage, risk assessments, patient rooms
- Modifier -25: Is that E/M service really above and beyond the norm?
- Long-Term Care Training Solutions
- Injections and infusions continue to confuse coders
- Get the facts on emergency department FAST exams
- Capturing start and stop times for infusions
- Searched