HCPro, JustCoding Inpatient - 2016 Issue 33 (September)
Deciphering diabetes documentation advice
September 6th, 2016
Subscribe or sign in to view the full article.
Article Overview
This article explains how recent AHA Coding Clinic discussion and the Official Guidelines for Coding and Reporting affect diabetes documentation review. It is written for CDI, coding, and clinical documentation staff who need to understand when documentation may support presumed relationships between diabetes and associated conditions, and when physician clarification may still be needed. The article also addresses documentation issues involving diabetic ketoacidosis when the diabetes type is not specified, within the broader context of ICD-10-CM diabetes coding guidance.
Why This Topic Matters
Diabetes documentation is a frequent source of queries and coding variation. Understanding the published guidance can help CDI and coding teams review records more consistently and identify when clarification is appropriate.
Article Sections
-
Coding Clinic and guideline clarification
Introduces the recent AHA Coding Clinic discussion and its connection to the Official Guidelines for Coding and Reporting. Focuses on the broader documentation and query implications for diabetes-related coding review.
-
The role of the term “with” in diabetes documentation
Describes how the article discusses the relationship between diabetes and associated conditions in the Alphabetic Index and Tabular List. Covers the general documentation review considerations raised by that guidance.
-
Diabetic ketoacidosis when diabetes type is not specified
Addresses the article’s discussion of documentation for diabetic ketoacidosis when the diabetes type is not stated. Frames the issue within ICD-10-CM diabetes coding and clarification workflows.
What You Will Learn
- How recent guidance is framed in relation to diabetes documentation review
- How the article discusses presumed relationships between diabetes and associated conditions
- Why unspecified diabetes type can affect review of diabetic ketoacidosis documentation
- What types of documentation questions CDI teams may still need to address
Who Should Read This
- Clinical documentation integrity specialists
- Inpatient and outpatient coding professionals
- Coding educators
- Revenue cycle and compliance teams
- Physicians and documentation improvement staff
Codes Discussed
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com