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Wound Care Documentation Case Study: Follow-Up Visits
When reviewing this case study, refer to the instructions given in the case study published in the January/February 2015 issue of Today’s Wound Clinic (as well as the series of ICD-10-CM Diagnosis Coding Documentation Tips that were regularly provided between October 2013 and December 2014) in an effort to evaluate your documentation practices. Remember: We are only working with the diagnosis codes in these particular case studies to reinforce the importance of documentation specificity, as that is a key element for data accuracy. The appropriate diagnosis code is also necessary for determining medical necessity.
Case Study: Follow-Up Visits by Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA
(Note: Code ICD-10 diagnoses information only.)
With this month’s topic, we will look at proper ICD-10-CM coding for follow-up visits to the outpatient wound clinic following inpatient surgery. We will also look at some existing conditions or status conditions that may impact the current visit.
A 68-year-old male patient living with type 2 diabetes is post kidney and pancreas transplant with cadaveric organs. Today, he is visiting the wound clinic for follow up of a recent amputation of the right foot as well as a nonhealing gangrenous ulcer of the left foot secondary to diabetic peripheral vascular disease. The amputation site has been examined and there is no evidence of infection or dehiscence.
Using the code table below and your ICD-10 codebook, properly code the diagnoses for this case.
For answers, visit the ICD-10 Column section at www.todayswoundclinic.com.
REMEMBER: Medical surveillance following completed treatment is always coded to Z-code as the first-listed diagnosis.
Donna Cartwright is senior director of strategic reimbursement at Integra LifeSciences Corp., Plainsboro, NJ, and an approved ICD-10 trainer by the American Health Information Management Association. She may be reached for questions at 609-936-2265 or at donna.cartwright@integralife.com.
For answers, click here.
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