Wiki dx coding help please

[SandyTrisler]

coding for pulmonary, the charge sheet says "multiple vascular wounds" and I have no access to any notes other than a face sheet that states dx is decubitus ulcer. other dx listed for this patient on the charge ticket includes: dry gangrene multiple toes, Massive DVT's, phlegmasia cerulea dolens, and anemia. would you use code 904.9 for the vascular wounds? Thanks so much!

 

[gost]

*sigh* This is one of those times when the rules and I tend to disagree, get into a heated argument and maybe even come to blows. Technically, you're right. The documentation says vascular wounds and you should code vascular wounds 904.9 even though you know it's not right. Do you have access to any other medical records? Maybe even a contact in an allied provider's office like pathology or radiology? Even better if you could talk to the doctor him/herself.

I think my decision on how to code this would depend on the service I was billing for and any other info I could scrape up. I belive the docs would document better if they knew how many sleepless nights they were causing. Then again, amybe not.