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Wiki Chief Complaing

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slivingston

Networker
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Location
Mechanicville, NY
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I have see other threads relating to this topic but they do not answer this specific question. I work in Wound Care and we are having issues with our providers giving us detailed information pertaining to the wound at that visit. If the Chief Complaint states patient is here for a right ankle diabetic ulcer but the wound is documented throughout the note as a surgical wound and the provider has not mentioned the diabetic ulcer would you still code the diabetic ulcer? This is an issue with our providers as they do debridement's and a surgical wound will not support this and we ask for them to describe the wound at that visit and why they are debriding it and we don't get that information. The diabetic ulcer would support the debridement but without it being documented anywhere other than the Chief Complaint I am hesitant to code it.
 
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