Kathy Posted Wed 01st of June, 2011 20:18:21 PM
If a patient consultation includes DMII as part of the final impression dx and is left out of the subsequent note, should the DM ICD code be dropped as well?
** Blood Sugar is recorded in the body of the note which would indicate DM dx **
SuperCoder Answered Thu 02nd of June, 2011 14:09:00 PM
If Final Impression says, "DM II" and body of the report says what you have already mentioned, I don't think we need to be worried if this "DM" documentation is missing in any other part of the report.
What is confusing is that you have mentioned "left out of the subsequent note". What do you want to refer to as "subsequent note"?
Kathy Posted Thu 02nd of June, 2011 15:33:56 PM
By subsequent note, I mean that the note printed for the following visit discludes mention of DM other than a recording of the patients blood sugar in the body of the note.
SuperCoder Answered Thu 02nd of June, 2011 15:41:21 PM
Since this is known as a chronic condition, and blood sugar finding is still there in the body of the report, then you can drop "DM II" from previous report's Final Impression to the subsequent report.