Pressure Ulcer present not documented by physician

KellyFeist@catholichealth.netKellyFeist@catholichealth.net
in Home Care Coding General
Can anyone tell me what process needs to be done here in order for me to code the P.ulcer? I called the Dr office and the nurse could not find any documentation on the the p.ulcer. My nurse has it on the Oasis as a stage 2 on the coccyx as she is looking after and applying ointment.

Thanks for any advice you can give me!

Comments

  • tstrauss@elevatehomehealth.comtstrauss@elevatehomehealth.com
    edited April 2017
    Cannot be coded as PU unless MD states it is a PU. You can ask clinician if she spoke with MD and he stated it was a PU. If so Have clinician write a addednum note stating MD stated wound was a PU.




    Traci Strauss RN, COS-C, HCS-D
    Clinical Reimbursement Specialist
    209-914-3521
  • KellyFeist@catholichealth.netKellyFeist@catholichealth.net
    What if Dr didn't even see PU but nurse knows to check for them and found this one? Can it still go on the Oasis and I just don't code it? How would we capture it in case it continues to get worse?
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