RE: open area

lkpengellkpengel
edited April 2017 in Home Care Coding General
We are seeing a pt. for therapy only. On the order MD noted "triple paste to L buttock open area site, daughter monitoring". Pt. lives in own apt. at ALF with wife.
Question----would you code? Maybe unspecified wound below top 6? Or get a nurse in to assess, but then really no skill.

Thanks,
Lisa

Comments

  • Nancy.Wolverton@kindred.comNancy.Wolverton@kindred.com
    edited April 2017
    Hi Lisa.
    I would wonder how an "open area site L buttock" would interfere with therapy sessions?
    SN can assess and observe for healing of a questionable site such as that especially if it might affect her mobility and response with therapy sessions. Medicare will pay for SN to assess response of low-skilled intervention to a wound making sure it heals, especially if drt is doing it.
    Since HH is holistic care no matter the skill provided, I would get an RN to admit and discover what the lesion is just to make sure it will not be a barrier to therapy success. My opinion for what it is worth.

    Nancy Wolverton RN, CCM, HCS-D
    Kindred at Home
    Little Rock, Arkansas
    501-508-8526
    Nancy.Wolverton@kindred.com
  • lkpengellkpengel
    edited April 2017
    Thanks Nancy----I believe that is a good idea as well. The case has already been opened by PT as we code on the back end. It's also beyond the 5 days however A SN assessment would still be warranted. Just unsure about coding at this point.

    Lisa
  • Nancy.Wolverton@kindred.comNancy.Wolverton@kindred.com
    edited April 2017
    When a clinician establishes a POC with their ordering physician, they both are establishing critical diagnoses that are pertinent to the clinician's POC and those that are not. Ask the therapist if this diagnosis should be added to his POC; is it pertinent to his POC or not?

    Nancy Wolverton RN, CCM, HCS-D
    Kindred at Home
    Little Rock, Arkansas
    501-508-8526
    Nancy.Wolverton@kindred.com
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