Wiki Outpatient hospital wound center - support for DX

[ksue]

I am new to wound care coding for a hospital outpatient wound care center. I have it in my brain that I need to have some type of doc. to support reporting of any DX but especially chronic conditions.

I know the coding guidelines state to report conditions that coexist.

Here is my example of a typical note:

Assessment notes: "Complex wound due to diabetic manifestations. Diabetic PN."
There is support for the wound however no support for the PN such as numbness or on Neurontin and no mention of the diabetes either if controlled on metformin etc. in the plans or exam, anywhere on the note.

I have been coding only the wound as complex and have been going back and forth on whether i should pick up the DM or DM & PN since these can impact the wound?

Can you tell me from a compliance standpoint if I am correct to just code the wound or should I be picking up the DM/PN even without supporting documentation/no plans since they could impact the wound?
Thank you much!!

 

[cherene]

Yes, you could and should capture the Diabetes w/polyneuropathy. ICD-9 and 10
Section IV, J: Code all documented conditions that coexist
Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management

Hope that helps,
Cherene