Since the primary codes for diabetes mellitus do not include whether a patient is using insulin or not, a second code must therefore be used to code that. For example, ICD-10 code: Z79.4, “Long term (current) insulin use”. The use of the word “long term” unfortunately does not ne...
I’ve seen entries that combined the type of surgery (eg, cataract) with the name of a particular surgeon. (And if that surgeon leaves the institution to go elsewhere, that entry becomes clutter.) A small army of “coders” in the billing department have the job of reading the clinical ...