We query for uncontrolled DM when the blood sugars are at 200 or greater and their medications are being adjusted (over a 24 hr period). Hgb A1C at 7.0 or greater - some doctors will use 6.5 as uncontrolled. We also query if they are having consistent bouts of hypoglycemia.
If a provider does document controlled or uncontrolled diabetes I will query. Also if they don't indicate type I or II.
Other times may be if I see them say "poorly controlled", "brittle", and so on; since the coders can't code those.
As far as clinical indicators, an elevated A1C above 7 is another good lab indicator or blood sugars that jump all over the place or are consistently elevated and the person is not on a corticosteroid are good reasons to ask a question.
Hope this helps.
Robert
Robert S. Hodges, BSN, MSN, RN Clinical Documentation Improvement Specialist Aleda E. Lutz VAMC Mail Code 136 1500 Weiss Street Saginaw MI 48602
It does help, thank you. What way do you word this query? Would you just give him the indicators such as A1C, DM2 documented in the record. Please clarify if this is controlled, uncontrolled, or undetermined?
I'm attaching the query form I use for this. It is in Microsoft Word 2007, so if you can't read it let me know. It is also a fill in form, but I'm sending the unlocked version so you can edit it if you want.
Under my comments, I may add something like, labs indicate an A1C or your notes indicated insulin adjustments are being made, or the patient's blood sugars have been elevated since admission. It all really depends on what you see in the chart. But as you'll see on my form, I also ask if there are other manifestations of the diabetes that should be documented.
Robert
Robert S. Hodges, BSN, MSN, RN Clinical Documentation Improvement Specialist Aleda E. Lutz VAMC Mail Code 136 1500 Weiss Street Saginaw MI 48602
There is an article called Diabetes classification integral to hospital quality measurement" ACDIS Oct. 6, 2008 States: "The criteria for uncontrolled diabetes is individualized by the treating physician; however a HgbA1C greater than 7% or multiple blood glucoses greater than 250 mg.dl usually indicate uncontrolled diabetes."
Comments
Other times may be if I see them say "poorly controlled", "brittle", and so on; since the coders can't code those.
As far as clinical indicators, an elevated A1C above 7 is another good lab indicator or blood sugars that jump all over the place or are consistently elevated and the person is not on a corticosteroid are good reasons to ask a question.
Hope this helps.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
Under my comments, I may add something like, labs indicate an A1C or your notes indicated insulin adjustments are being made, or the patient's blood sugars have been elevated since admission. It all really depends on what you see in the chart. But as you'll see on my form, I also ask if there are other manifestations of the diabetes that should be documented.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
States:
"The criteria for uncontrolled diabetes is individualized by the treating physician; however a HgbA1C greater than 7% or multiple blood glucoses greater than 250 mg.dl usually indicate uncontrolled diabetes."
Charlene