ulcer coding
Patient has diabetes and MD has documented pretibial ulcers bilaterally. The nurse has documented those ulcers along with ulcers on her calves and wants those coded as well. The MD documentation I have only says pretibial and nothing about calf, her point is that they are using more supplies because there are more than the 2 ulcers that I coded. I know that we can use nursing documentation for severity but we can't use it for location can we??