Wiki Facility side - Lac repair with no size documentation

[ashack63]

We have been going back and forth with this question. When a Lac repair is documented, suture count, wound description, etc... and the SIZE of the wound is not documented, do you code to the lowest for the anatomical site, or do you Not code at all.

 

[kayroserey@cox.net]

You go to the provider and let him/her know that the documentation is missing important information and needs to be amended...then you code.

 

[ashack63]

And if facility has procedure to not query provider?

 

[donna_vig]

Then you would default your code to the smallest size in that code section. For example: Doc marks 12002 on sheet but did not document size in his documentation and your policy is not to query the physician. It would default to 12001 for the 2.5cm or less. This is per guidelines. I hope this helps!