Documentation requirements for coding PAD with wound

Coastal Coder

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Good Morning all,

I am coding for general surgery and one of my Dr's does vascular. We are in a debate over how to document and code for a patient with PAD with a wound of the calf. The patient is being followed for the wound by another office and the wound is wrapped. My Dr is not documenting wound depth in his note. It is in the guidelines for ICD 10 code I70.232 (use additional code to identify severity of ulcer L97.-)

My question is this, if I do not list the wound depth code as well as the PAD code will this cause us to be audited for not coding to the highest specificity?
Any suggestions on what I should do?

Thanks so much is advance for help with this issue

Michelle
 

LuckyLily

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Code I70.232 code needs to have the L97.--- code to go with it. Since you do not know the depth, the doctor should state that it is wrapped and cannot determine the severity of the ulcer. You then use L97.--- Ulcer, skin, lower limb, calf, left/right, unspecified. This will give you the code to go along with I70.232
 

cherene

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Denver, Co
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Coding PAD with wound

Good Morning all,

I am coding for general surgery and one of my Dr's does vascular. We are in a debate over how to document and code for a patient with PAD with a wound of the calf. The patient is being followed for the wound by another office and the wound is wrapped. My Dr is not documenting wound depth in his note. It is in the guidelines for ICD 10 code I70.232 (use additional code to identify severity of ulcer L97.-)

My question is this, if I do not list the wound depth code as well as the PAD code will this cause us to be audited for not coding to the highest specificity?
Any suggestions on what I should do?

Thanks so much is advance for help with this issue

Michelle

You can not code an "ulcer" if the documentation states "wound". Coding should be PAD w/"wound", no depth etc. required.
 
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