What should be reported when diabetes affects the provider's medical decision making but is not being treated?

When diabetes affects the provider's medical decision making but is not being actively treated, it should be reported as an additional diagnosis. This is due to the impact that the diabetes has on the patient's overall health and the medical decisions being made in their care.

Even if the condition is not currently being treated, it is still relevant and necessary to document it within the medical records. This helps to capture the complete clinical picture, especially as it can influence the management of other health issues or conditions that the patient may have.

In coding and billing, accurately reporting all relevant conditions supports proper reimbursement and reflects the complexity of the patient’s health status. Thus, categorizing diabetes as an additional diagnosis ensures that the medical records and claims adequately reflect the patient's challenges, which is essential for both clinical care and administrative processes.