Wiki ICD 10 Doubt

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Nallathambi

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Hi sir I have one doubt in ICD 10

Patient came to the hospital for heel wound , patient had multiple surgery on heel.

Final diagnosis documented as surgical Chronic left heel wound- healing with no signs of active infection

Please sir, write ICD 10 code this scenerio
 
have you made any attempt to code this? What are your thoughts? I would like to see your attempts before I make a siggestion. If I just give you a code you really do not learn anything. Also is there anything more in the documentation.. Is this a visit to change dressings, is it just a follow up, or is this another surgical encounter for wound debridements. It really does matter exactly how it is described in the note. Also is it a diabetic ulcer or a pressure ulcer. Is it due to PVD. There are so many different ways this could be coded and it really depends on the note and not just the final diagnostic statement.
 
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Assessment and Plan:
1. Chronic left heel wound- healing with no signs of active infection
2. Right 2nd digit- purulent drainage- no surrounding erythema/edema
3. DM
4. PVD
5. S/p abductor flap, left foot
 
I see but what does the note say? This is just a list of diagnosis, how does the physician document the condition. It will matter if it is a condition that is due to the diabetes. If it is a pressure ulceration. You cannot select the correct codes from just a list you need to see how the provider put it all together in the context of the note. I see many different possibilities with this listing, but now only questions not answers. And you need to provide what you would code and why.
 
ICD 10 Doubt response

After reviewing the available information, I see a significant lack of accurate documentation for all the listed diagnoses: What type of Diabetes does the patient have?, If not Type 1, does the patient normally get insulin as supplemental treatment in addition to his oral agents (If so, then needs Z79.4 code added)?, Does the patient have Diabetic Neuropathy with ulcer?, Is the Peripheral Vascular Disease an isolated disorder not related to his Diabetes, or is it secondary to his Diabetes? All of these effect the coding of this scenario. L97 code set covers Non-pressure Chronic Ulcer of the Lower Limb, and Includes Non-healing ulcer of skin. L97.42_ would be for the left heel and mid-foot, but the depth of the wound is not documented (6th character of the code). But, it says First Code the underlying condition(s), i.e. the codes that best answer the questions above, many of which are Combination (Manifestation) Codes for Diabetes and/or Peripheral Vascular Disease.
From Alan Pechacek, M.D.
 
Documentation

I just want to chime in a say that I wound be so grateful to have as much detail as the op does to go off of. You'd be surprised how little some providers document. The coder needs to be able to abstract valid data regardless.
 
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