Wiki Coding an amputation from surgical history in EMR

[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.

 

[Sarah Ann]

You can't code from lists- (like problem lists, medication lists, surgical lists etc.)codes should be captured from the physician documentation itself.
Other sources of documentation(like nursing documentation) you can use is - BMI, depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, stroke scale, SDOH, laterality, blood alcohol level, and underimmunization status. The examining provider would need to document this status within the encounter note. OP encounters are stand alone encounters. If during the exam he/she documents absence of a toe, then I would capture this, it's a status code. Other than that just because it will never grow back does not mean it can be captured without the provider documenting this within the encounter on the date of service. This is how I deal with lists- I ignore them.

 

[terastewart]

You can't code from lists- (like problem lists, medication lists, surgical lists etc.)codes should be captured from the physician documentation itself.
Other sources of documentation(like nursing documentation) you can use is - BMI, depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, stroke scale, SDOH, laterality, blood alcohol level, and underimmunization status. The examining provider would need to document this status within the encounter note. OP encounters are stand alone encounters. If during the exam he/she documents absence of a toe, then I would capture this, it's a status code. Other than that just because it will never grow back does not mean it can be captured without the provider documenting this within the encounter on the date of service. This is how I deal with lists- I ignore them.

Thank you so much for responding, Sarah! I appreciate your time!