Skin tears noticed by clinician, not physician
I cannot believe I haven't had this problem until now... We are caring for this patient's pressure ulcers and monitoring their ESRD. The RN upon ROC for this patient noted she is caring for skin tears to the right shin and left thigh.
These were not noted by any physician, but the RN did note her care for it in her written order to the referring physician (which is not yet signed).
Can I code these??