nicoleysmith
Networker
I have been reading the many threads on the forum regarding a non-healing/delayed-healing surgical wound, but none quite fit my situation (of note: I work in a clinic where the provider enters their codes and a coder checks them).
Patient had a MOHs surgery for removal squamous cell carcinoma in December 2019.
Patient has a follow-up with the MOHs surgeon in February 2020 with a chief complaint of "Check surgery site" and an HPI of "surgical site much improved, but healing seems to have stalled"
Physical findings list the patient's height and "surgical scar on the left helix - very tender to the touch, small crust/scab"
Office procedures list "Office Procedures 1. non healing wound - infection vs CDNH - wound culture today- may do steroid injection next week if wound culture negative 2. wound on the right cheek - BCC vs irritation from CPAP machine - consider biopsy if doesnt heal"
Documentation also lists Active Problems & Current Medications.
Provider has coded 11042, C44.229.
Aerobic bacterial culture was ordered with C44.229.
Questions:
1. is that enough documentation to code for a debridement?
2. how do I code a diagnosis of "non-healing wound" when there is no definitive malignancy, infection, surgery complication, or late effect of the original neoplasm?
3. Can I code diabetes mellitus from the active problem list as a co-morbidity even if the dermatologist doesn't address it?
I recently started coding MOHs and the documentation is sparse, so any help is greatly appreciated. This one is tough!
Patient had a MOHs surgery for removal squamous cell carcinoma in December 2019.
Patient has a follow-up with the MOHs surgeon in February 2020 with a chief complaint of "Check surgery site" and an HPI of "surgical site much improved, but healing seems to have stalled"
Physical findings list the patient's height and "surgical scar on the left helix - very tender to the touch, small crust/scab"
Office procedures list "Office Procedures 1. non healing wound - infection vs CDNH - wound culture today- may do steroid injection next week if wound culture negative 2. wound on the right cheek - BCC vs irritation from CPAP machine - consider biopsy if doesnt heal"
Documentation also lists Active Problems & Current Medications.
Provider has coded 11042, C44.229.
Aerobic bacterial culture was ordered with C44.229.
Questions:
1. is that enough documentation to code for a debridement?
2. how do I code a diagnosis of "non-healing wound" when there is no definitive malignancy, infection, surgery complication, or late effect of the original neoplasm?
3. Can I code diabetes mellitus from the active problem list as a co-morbidity even if the dermatologist doesn't address it?
I recently started coding MOHs and the documentation is sparse, so any help is greatly appreciated. This one is tough!
