Words count: Don’t code “poorly controlled” diabetes with “uncontrolled” code

Article Overview

This short coding guidance article addresses how ambiguous diabetes documentation should be handled when a provider describes the condition as poorly controlled rather than clearly uncontrolled. It is aimed at coders, billing staff, and compliance-minded clinicians who need to understand when physician clarification is necessary and why documentation quality matters for accurate code selection. The article also references Coding Clinic guidance and the role of provider education in avoiding assumptions.