I have read the coding rule for diabetes poorly controlled, out of control and hyperglycemia and the fact that uncontrolled phrase should not be used anymore but rather specifying the glycemic episode. But i have not seen in all those whether diabetes Mellitus with Hyperglycemia can be always documented by physician without having a hyperglyceminc episode or event whether symptoms level (dryness, urinary problem,…) or blood glucose level (showing elevation despite following diabetic regimen coarse,…) (and thus coded during the overall treatment/management coarse and follow ups). Some physicians have their clinical judgement that diabetes condition by default is out of control (hyperglycemic) and will be better controlled by the medications (oral+/-insulin). If hypoglycemia was the situation, this will certainly need documentation for the hypoglycemic event not like hyperglycemia. Thus, coder will always query the physician about the origin of diagnosis "diabetes with hypoglycemia".

Can you please let me know if query process will be needed when documentation just state poorly controlled without additional info.?

Thanks
Jibin zachariah CPC CPMA
01161432