Chronic Conditions Diabetes and Hypertension
I would like to get your opinions on this scenario, in the context of so many patients having diabetes and hypertension together. I realize this is an educational opportunity.
An unusual case has popped up where a patient presented for atrial fibrillation with RVR. Patient also has diabetes and hypertension mentioned in PMH. The Cardiologist mentioned in the body of his consultation one time "diabetes with secondary hypertension". I personally have never seen this type of specificity documented before. In the discharge summary, the attending physician continued to just copy and paste in the list 1)Atrial Fibrillation 2) DM II 3) HTN.
So, here are my questions. Can we use the one time more specific description by the Cardiologist without querying the attending? Do you feel the appropriate more specific codes of E11.59 and I15.2 would be appropriate without further documentation to support it? What and/or how is Hypertension due to diabetes or a secondary hypertension determined to be due to diabetes based upon. Would you query the attendings on this clinical type case so there are so many opportunities for these two chronic conditions? The specificity provided by the cardiologist increases the SOI and ROM score but is not consistently documented. I think this is an area where the attending physicians would need to provide more specificity in these two chronic conditions. E11.59 is Type 2 diabetes mellitus with other circulatory complications. I15.2 Hypertension secondary to endocrine disorder. What are your thoughts???
An unusual case has popped up where a patient presented for atrial fibrillation with RVR. Patient also has diabetes and hypertension mentioned in PMH. The Cardiologist mentioned in the body of his consultation one time "diabetes with secondary hypertension". I personally have never seen this type of specificity documented before. In the discharge summary, the attending physician continued to just copy and paste in the list 1)Atrial Fibrillation 2) DM II 3) HTN.
So, here are my questions. Can we use the one time more specific description by the Cardiologist without querying the attending? Do you feel the appropriate more specific codes of E11.59 and I15.2 would be appropriate without further documentation to support it? What and/or how is Hypertension due to diabetes or a secondary hypertension determined to be due to diabetes based upon. Would you query the attendings on this clinical type case so there are so many opportunities for these two chronic conditions? The specificity provided by the cardiologist increases the SOI and ROM score but is not consistently documented. I think this is an area where the attending physicians would need to provide more specificity in these two chronic conditions. E11.59 is Type 2 diabetes mellitus with other circulatory complications. I15.2 Hypertension secondary to endocrine disorder. What are your thoughts???