Did you know? There are very specific documentation requirements for accurately describing your patients’ diabetes status.

1. The cause of the patient’s diabetes must be specified

  • Type 1
  • Type 2
  • Secondary to another cause such as chronic steroid use, chronic pancreatitis, post-pancreatectomy, etc.
    Note: insulin dependency not important for diabetes documentation or coding

2. Please document all known complications that occur or have resulted from their diabetes

  • Hypo- or Hyperglycemia (not “uncontrolled”)
  • DKA or HHNS
  • Neuropathy – Peripheral or Autonomic (Does the patient use sildenafil or tadalafil?)
  • Retinopathy
  • Vasculopathy
    Note: Please also document any concurrent peripheral vascular disease
  • Nephropathy
    Note: Please also document any concurrent chronic kidney disease including the stage of 1-5)
  • Skin ulcers or dermatitis

Excellent Documentation Examples:

  • DM Type 2 with hyperglycemia and CKD, stage 3
  • DM Type 1 with DKA and PVD s/p R foot TMA

Download the complete tip, Diabetes Documentation.