We do a lot of lower extremity duplex scans. The clinical data on the report from the hospital is cellultis, chronic wound to left foot with indications of pain, type 2 diabetes, hypertension and smoking.
What diagnosis do I use? The patient has cellulitis, chonic wound, pain and is diabetic.
To me a chronic wound equals an ulcer and since the patient is diabetic would I code E11.621 then cellulitis and pain?????????????
Thanks,
You should be coding what's relevant to the service; what's the purpose or reason the scan is being ordered? You can't assume anything, as obvious as it may appear, such as the chronic wound being an "ulcer" - the provider has to document that specifically.
This is how I interpret the information. The patient has DM, HTN, and is a smoker. He/She is experiencing cellulitis and a chronic wound with pain present. We know what conditions/diseases the patient has, but we
don't know if the cellulitis and/or the chronic wound is/are directly related to the established conditions/diseases. So the purpose of the scan is to help determine if they are attributable to the DM, HTN, smoking, etc. I'm a bit stuck on the cellulitis because it doesn't specify the location and I don't want to make an assumption about where it is.
If it were me, considering that a duplex scan looks at blood flow, I would be inclined to code for the left foot pain M79.672, and probably L03.90 Cellulitis, unspecified (as much as I hate unspecified codes), E11.9 for the DM, and I10 for the HTN.
However, just to clarify, is "cellultis, chronic wound to left foot with indications of pain, type 2 diabetes, hypertension and smoking." a direct quote from the documentation?
