Health Information Management

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

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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.

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