Wiki Wound Care Documentation

[slivingston]

I am new to wound care coding and we are having trouble getting specific documentation to code from.
One of the ways they like to document is "Wound 1 Abdomen is a full thickness soft tissue necrosis" later in the note they will put "The abdominal and groin wounds are soft tissue necrosis wounds due to necrotizing infection that occurred in 12.2023", then they will choose DX L98.495 - non-pressure chronic ulcer of skin or other sites with muscle involvement without evidence of necrosis.
- we have asked them to be more specific in the wound assessment documentation and also to pay attention to the code selection as it is contradicting. I am trying to find education I can provide to them that shows they need to specificially notate in the wound assessment that this is an ulcer not necrosis since this is what they are currently being treated for not what this wound started as. Can anyone direct me to some education that I can review and provide to our providers?

 

[carlystur]

Sigh. Providers should not be coders. They quite often don't have time to learn all the ins and outs of diagnosis coding guidelines.

Unfortunately, I do not have an answer for you as I think my providers have a similar issue, but a different specialty and different problems. Only the most specific causal diagnosis should be chosen as the assessment (including any co-existing conditions that affect the care of the patient). My providers have the hardest problem with this as they are always choosing differential diagnoses and other symptoms of the causal diagnosis that they are treating in addition to all other co-existing conditions the patients have - regardless of their relevance to the visit in the slightest.