ICD DM II Uncontrolled

[Chaim]

Progress note under assessment sts DM2 - high fbs, hba1c 7.0 - on no meds.

Under plan sts spoke to wife about diet - pt will try and controll DM and dyslipidemia with diet. if not under control in 4 months, consider meds.

I remember Alicia stating that the doctor needs to specifically state "uncontrolled." But if he is not dieting yet nor taking meds or any other measures to control it - would that mean it's uncontrolled.

Even though it is not directly stated within the assessment, but it is mentioned within the plan that he plans to try and control it, can I still code it as 250.02?

Thanks.

 

[louise]

Chaim,
I agree with Alicia. The medical record needs to specifically state the the diabetes is uncontrolled before using 250.02. Reading that meaning into the record by putting together mention about his diet, lab values, etc, is not allowed. Additionally, I think 'uncontrolled' means that one or more means of control have been attempted and have failed to control the diabetes.

Thanks for the great question! I'm looking forward to Alicia's thoughts on this one.