Was the Hyperglycemia Due to a Bottle of Bad Insulin?
Shannon was diagnosed with Type 1 diabetes at 9 years old. According to the American Diabetes Association, “Type 1 diabetes is usually diagnosed in children and young adults, and was previously known as juvenile diabetes. Only 5% of people with diabetes have this form of the disease.” (American Diabetes Association, 2017) A diagnosis requires at least two Hemoglobin A1C measurements of 6.5 or higher, which indicates the average blood sugar level for the past two to three months per test. (Mayo Clinic, 2017). For fifteen years, Shannon had relied on a combination of 3-5 insulin shots daily to help manage her diabetes. Fortunately, at the age of 24, Shannon started using an insulin pump along with T-insulin to manage her diabetes. At 48 years old, a splitting headache was the first sign that started a terrible two day experience for Shannon. During the two days, Shannon had experienced five health conditions or symptoms. After a review of this case along with 1) the appropriate coding books, and 2) the included policy and procedure handout (Appendix A), the student will be able to 1) assign the appropriate diagnosis codes, and, 2) write a policy and procedure for a patient registration process. Determining the primary diagnosis was complicated by the patient having multiple conditions and symptoms.
- Develop the criteria and steps for checking in a patient at the medical office.
- Evaluate the steps for checking in a patient at the medical office.
- Identify steps the release of information clerk can take to ensure release of information is done properly.
- Develop a policy and procedure for the patient check-in process.
- Identify the primary diagnosis/diagnoses for the first encounter and the second encounter.
- Discuss how one arrives at the ICD-9, ICD-10 and CPT codes for the encounters.