Medical Decision Making Uncontrolled Diabetes

Our next case example that I’ll have you walk us through is a patient with uncontrolled diabetes.


Okay, so just on the outset, even if we say this is one problem and it’s definitely not stable. So, at the very least we’re going to fall into moderate level. Now if the blood sugar happens to be 600 or 800, or one time I had a patient that was about 1,400 on presentation. Now we’re talking about acute or chronic illnesses to life and bodily function. And that may fall into the high category or the high-risk element. So easily moderate or level four, potentially a level five. The data complexity, so this can easily fall into moderate or high depending on external test review, review of the results of a test that you may have ordered. Blood glucose, hemoglobin, A1C, you may be looking at a metabolic panel to see if the patient is onto ketoacidosis. So, there’s a number of things that you could probably meet in category one. You’re most definitely, at least in my case, I would probably have a discussion with another physician on the management or even test interpretation. So, we’re probably going to meet high or level five, even with that, easily level four. And then under the morbidity and risk of complications of patient management, we may or may not be participating in the prescription drug management. In some states already, there’s predicted to be such a shortage of healthcare providers that optometrists with their knowledge level relative to diabetes may be pushed into even primary management of diabetes. But we’re probably not going to meet the element regarding minor surgery with unidentified procedure risk or elective major surgery, but we may have, we may meet the criteria for diagnosis and treatment of significantly limited by social determinants of health. So, at the very least level four, potentially level five. And so, in my particular case, most of the time in our practice we would have thrown out just about anyone of those and still ended up at moderate. We wouldn’t have ended up at high, because except in the case of the really high, fasting blood glucose and then we got maybe two components in the high and one in moderate. So throw out the moderate and we’re still at a level five. So your uncontrolled diabetic falls into the purview of debatable coding and would really be up to your discretion after you’ve reviewed both the history of present illness, the chief complaint, and the review of systems, along with your medical decision making. But I doubt seriously that you would ever end up with less than a level four and from time to time a level five. So, thank you Maritza.


Thank you. And I think this is definitely a great example of how to maybe go from a level three of maybe what you would have coded previously and now into a level four into 2021 and really the reimbursements reflect the work done. If you’re ordering appropriate tests and you’re having discussions with outside physicians, now it’s just a very clear, direct way to kind of get to that understanding just a little bit easier of how you qualify for a level four.