OASIS Alert

Published on Fri Apr 04, 2014 PDF

Your intake staff can gather the details you need to prepare for your patients. But they’ll need some training to make sure they know when to dig deeper.

For example: Suppose a referral source wants to send over a patient with multiple wounds. That sounds pretty clear at first glance, but then the progress notes come over with a trauma diagnosis to describe the wounds, and comorbidities of diabetes, CVA, and peripheral vascular disease. “The intake nurse needs to know immediately that we need to confirm that these are actually trauma wounds, because in many cases they are not,” says Delaine Henry, COS-C, HCS-D, with Health Care Management and Billing Services in Lafayette, La. With proper training, intake could recognize that those wounds are more likely diabetic or diabetic PVD wounds, or perhaps arterial or stasis ulcers unrelated to diabetes.

To code those wounds correctly, you must know three things, Henry says:

• Are these wounds truly traumatic?
• If not, are they related to the PVD?
• If so, is the PVD a manifestation of the diabetes?

With a little training, intake staff will know to ask “What kind of wounds are these?” and “Are they caused by something else?” With the answers to these questions, you can code the patient properly, and make certain the physician documents the wound information correctly on the face-to-face visit. “Because nothing is more fun than admitting a patient only to get the F2F a month later with entirely different diagnoses on it,” Henry says.

With actual trauma wounds, you’ll need even more information in ICD-10, says Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates, LLC, CoDR—Coding Done Right and Code Pro University in Denton, Texas. Some examples of trauma wounds include lacerations, bites, and amputations. Make sure your intake staff knows what’s required to make the best code selection.