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  • agree, only if md states total colectomy was performed.
  • Thoracoscopy is a surgery, so aftercare respiratory is appropriate. Post thoracoscopy, a chest tube is usually placed in the surgical site- so it is usually done all through the same incision. That code would encompass chest tube site.
  • I would say only if there was a TOTAL colectomy. If part of the colon exists, there is a possibility for disease in the other portions of the colon. May be best to ask the physician.
  • This is just what I would think clinically.. As long as the stoma is still open, it is still considered a trach/stoma. If clinician is rendering wound care, then I would say, yes- "Attention to tracheostomy" is appropriate.
  • needs to be specified by MD differentiating/diagnosing between an acute or chronic condition is not within a RN's scope of practice. I would ask clinician to call MD to specify, or if you are a RN, you could call MD and take order and note it in p…
  • MD/NP needs to state it.
  • code what is likely to impact the POC. Anything respiratory related would impact the poc bc it would be a barrier for endurance and exercise tolerance. bipolar/schizo I would say yes bc the mental status will impact the patient's compliance to the p…
    in PT ONLY Comment by rgalatioto February 3
  • I was under the understanding that you had to use the codes that were in effect for the episode SOC date. If I can find documentation to support this, will let you know.
  • That is info that I received in person during coding seminar from Sparkle Sparks with OASIS Answers, who is an instructor/AHIMA certified coder.
  • It should not be used for Pressure injury/wounds, but you can use Z48.00/Z48.01 for any other wound or surgical wound that is receiving RN assessment and or wound dressing changes.
  • best thing would to ask MD. it is likely not a surgical dehiscence 2 years later. most likely just a traumatic wound. If md says wound is from trauma, then code it as trauma. if they correlate it to a complication of the surgery, then code the T cod…
  • You would not code the muscle weakness in addition to Parkinson's, because it is integral/a manifestation of Parkinson's. The back pain is a different story. If there is no definitive dx for the cause of the back pain, I would code the back pain in …
  • I review the OASIS and code. I am an RN with COS-C certification, and actively working on obtaining HCS-D certification.
  • was there dehiscence or infection of the wound? Then code the T code for the wound.
  • yes, we code ROC's agency wide.
    in ROCs Comment by rgalatioto November 2017
  • you could use the copd exacerbation in your oasis, but the exacerbation is likely resolved if they are being discharged home. So- I would just use the J43 code.
  • agree with michelle
  • nope. the dependence on dialysis code encompasses the presence or a fistula.
  • You could use L89.4X (Insert last digit for stage)
  • agree with @elstewart.
    in Z48.00 Comment by rgalatioto July 2017
  • If it was the surface wound, I would use T81.4XXD. I would only use Infection of knee prosthesis code only if it were Physician confirmed and documented. Code additional code if you know specific bacteria causing infection. Sepsis code only if docum…
  • That's a toughie. I was always taught that you only code for infections when antibiotics are on board and condition is being actively treated. If you get a concrete answer, let us know?
  • With T81.83XD, the description of the code is PERSISTENT post operative fistula following a procedure. I wouldn't use that code unless it were provider confirmed that the cause of the fistula was the surgical procedure and that it was persistent. If…
  • If documented as present at SOC, yes. If someone had GB years ago and is no longer obese, then no. In that case you would just answer in M1036 of OASIS, yes for Obesity.
  • Once the surgery is performed, the ulcer is gone, so I would think there is nothing to code for it? You could capture the presence of DM ulcer in M1011/M1017 of OASIS for CMS. Conditions that are considered resolved should not be coded. I would cod…
  • You can use the code for Hypertensive heart disease with CKD and heart failure - I13.0 (Combination code). Then code N18.9, and then type of HF. For DM, you can use code E11.22
  • Nope, you can't ASSUME patient has DM, as some DM meds are taken for other medical issues. The clinician (or you if you are a RN) can put a call in to MD to confirm Dx of DM and write a note in patient's medical record reflecting that. Then, at that…
  • I don't believe there is one for stents. I know there's one for presence of coronary bypass. I would just code the underlying condition- CAD I25.10 or Old MI I25.2
  • I have been to the OASIS Answers ICD-10 2 day seminar. Highly recommend.
  • HTN Also??