coding

maryjane11

We have a patient that was adm. for wound care. Per referral pt develop ischemia with gangrene to bil. heels, rt. index finger, lt arm, lt 2-5 finger and scalp d/t medication that was received during a hospital adm for UTI. MD or hospital not providing information on what med. MD states as DM ulcers now which is not the case. Any help on how to code. 

Brenda

Our process is that I, the coder, receive a Dx list to assign codes to from the nurse clinician. So if the clinician doesn't list neoplasm or hx of neoplasm, am I supposed to find it in med recds and add it myself or should I have the nurse add it, and sequence it as she decides it should be?


Brenda Hoss
Coder

Nancy.Wolverton@kindred.com

Hi Brenda,
I read your inquiry and felt compelled to chime in. Here's my 2-cents worth...
A HH Coders' job is to review the Medical documentation available while understanding from the clinician what the focus of care is for that POC they are coding, and then make recommendations for codes to be used for their POC.
One must never forget that it is the nurse's POC developed in corroboration with the ordering physician and the patient. The coder does NOT enter onto the POC as the coder is not responsible for the POC orders. It is the RN's ultimate responsibility to take the coder's recommended codes and utilize them. If they do not and their claim submitted fails, then they are responsible for it, not the office staff. The Primary RN owns the entire case. A coder, intake staff, billing staff, etc and all back-office personnel to assist the RN with their case, not to directly influence it or do it for them.

Nancy Wolverton RN, CCM, HCS-D-10
Utilization Review Specialist
Kindred at Home
Little Rock, Arkansas
501-508-8526 (o)
501-690-2027 (c)
Nancy.Wolverton@kindred.com

vmirabella@utopiahomecare.com

According to the guidelines, if cancer has been excised but needs further
treatment- it is coded. If it is unclear of the cancer has been eradicated,
assign the cancer. If the documentation indicates that it has been
eradicated clearly, assign Z85 code.

I was in the same position as you and I asked my office to purchase the
Home Health ICD-10 diagnosis Coding Manual and coding has become so much
easier. There are additional coding tips that are just wonderful.

vmirabella@utopiahomecare.com

I also ,forgot to say, you need to code Z48.3 as primary. Also, read the
medical records for any additional information to help your coding.

vmirabella@utopiahomecare.com

Any discrepancies or questions, you can either call the clinician or call
the MD. If there was cancer removed either way you have to know what it is
for the OASIS.

prissyb@nursesunlimited.com

You have to have the H&P or MD's progress notes to support your codes. I
would suggest do an aftercare for neoplasm and follow it up with your
neoplasm code. PB