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?)
Note: Please also document any concurrent peripheral vascular disease
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.