Uncontrolled Diabetes

vanessa.falkoffvanessa.falkoff
in CDI Talk Archive
Hi,
Does anyone have a clinical definition of "Uncontrolled Diabetes" they
could share? What would you do if the physician checked Uncontrolled DM
type II on a query and the coder felt that the DM was not "uncontrolled"
per the rest of the chart?
Thanks in advance for any wisdom you are able to share :)

Vanessa Falkoff, RN
Clinical Documentation Coordinator
University Medical Center of Southern Nevada
office (702) 383-7322
cell (702) 204-0054
vanessa.falkoff@umcsn.com

Comments

  • Unknown
    edited May 2016
    I go by an article I read from ACDIS. I cannot remember the name but the parameters were:

    HgbA1C above 7 and multiple blood glucose greater than 250.



    Charlene

  • ssalinasssalinas
    edited May 2016
    I would be really interested in other's response to the second question
    in email below -expanding the question to any diagnosis i.e. sepsis,
    respiratory failure, etc. listed by physician throughout a chart but
    lacking clinical indicators.

    What would you do if the physician checked Uncontrolled DM
    type II on a query and the coder felt that the DM was not "uncontrolled"
    per the rest of the chart?

    Sharon


  • paxnerospaxneros
    edited May 2016

    I would be interested in this as well. We are having the issue of
    "over-documentation" at this time. (Feast or Famine)

    My current solution is to speak w/ the physician(s) personally through an
    "educate me please" approach and then informing them of RAC and other
    auditors findings regarding the diagnosis and lack of clinical support.

    When I see the offenders I educate them by letting them know how we get
    slapped on the hands regarding this type of documentation.

    I know "reverse queries " have been talked about w/ mixed feelings. Also it
    can be considered questioning their clinical judgement. Other than
    documentation tips in the physician newsletters.... any other ideas?

    NBrunson, RHIA,CDIP, CODS!
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    The guidance I have received from our coding manager is that if severity had not been indicated elsewhere in the record they would code “uncontrolled” from the query. If the patient was initially stated as “controlled” and then had a change in status and required treatment for their DM and the MD then responded that it was “uncontrolled”, they would code this too. The time that there would be an issue is if the patient was stated as “controlled” in the record and then a query was placed and the MD stated “uncontrolled” on the query when there was no change in status/treatment and/or later documentation stated “controlled”. In this case, a query should be placed by coding stating that there is conflicting documentation and asking for clarification.
    I think this issue is problematic because a patient could very well have controlled DM on admission, Uncontrolled DM during the admission requiring extensive monitoring, changing of medication regimen and/or insulin drip, but then have controlled DM by d/c (which may be documented this way in the d/c summery).

    Regardless, my Coding manager always says that it is not the Coders job to decide whether they agree/disagree with a dx. It is their job to transfer the dx that the provider has documented into a set of codes. If there is conflicting/confusing documentation in the record, this should result in a query, not omission of a dx.


    As for the criteria for uncontrolled DM, I basically agree with what others have said

    · Multiple BGL> 200 or 250 (I have heard different things)

    · Fasting BGL> 125

    · OR, A1c >7

    This does not mean that the A1c must be >7. Many patients have controlled DM prior to admission and then develop uncontrolled DM as a result of illness.


    Katy Good, RN, BSN, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

Sign In or Register to comment.