Wiki Amputation - coding status code from past surgical coding

[terastewart]

Hello -

There has been much debate among professional coder, CDI, and leadership whether or not an amputation can be coded from just being in the surgical history within the documentation from an office visit. Some say that there has to be proof that the clinician discussed it or recognized the patient has an amputation while others state that since it is something that is permanent and cannot grow back, that surgical history is enough. Please let me know your thoughts. And, if you have any resources regarding this that you can share, that would be splendid.

Thank you for your time.

 

[miriambroyles]

In my opinion, best practice would be for the provider to support the amputation in the exam findings with the correct laterality documented. I've seen surgical history stating "below knee amputation," however, at the time of visit it was documented in the exam that the patient had since undergone an above knee amputation to the same leg. So, coding from the surgical history alone would have been incorrect.