BrennaC
New
Hello!
I have a few questions regarding coding related to this visit to our clinic.
Here are the provider's notes:
"- Consulted with Dermatology PA regarding nail condition; identified green discoloration under nail as likely pseudomonas infection, possibly due to trauma from acrylic nails.
- Informed about pseudomonas infection under the nail and its potential cause from acrylic nail trauma.
- Started gentamicin 0.3% solution, 2 drops applied under affected nail 3 times daily for 10 days."
1. This patient was seen in our clinic (outpatient), but a culture was never taken to prove the pseudomonas.
Since it's stated as "likely pseudomonas," my first instinct is not to code a pseudomonas infection. From what I've seen, an unconfirmed infection should not be coded as confirmed unless it's stated as "evidence of." However, the provider did treat the condition as if it were pseudomonas, and it did end up getting better with this treatment.
The provider coded this as A49.8 Other bacterial infections of unspecified site. Of course, the code should be more specific.
Would you code this as:
L08.89 Other specified local infections of the skin and subcutaneous tissue, B96.5: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere?
If not, how would you code this?
2. Aside from Flu and COVID-19, when is it okay to code for a specific bacterial/viral/fungal infection without a definitive pathology report if the physician DOES state that that is the cause of the infection (e.g. no swab was taken)?
Thank you!
I have a few questions regarding coding related to this visit to our clinic.
Here are the provider's notes:
"- Consulted with Dermatology PA regarding nail condition; identified green discoloration under nail as likely pseudomonas infection, possibly due to trauma from acrylic nails.
- Informed about pseudomonas infection under the nail and its potential cause from acrylic nail trauma.
- Started gentamicin 0.3% solution, 2 drops applied under affected nail 3 times daily for 10 days."
1. This patient was seen in our clinic (outpatient), but a culture was never taken to prove the pseudomonas.
Since it's stated as "likely pseudomonas," my first instinct is not to code a pseudomonas infection. From what I've seen, an unconfirmed infection should not be coded as confirmed unless it's stated as "evidence of." However, the provider did treat the condition as if it were pseudomonas, and it did end up getting better with this treatment.
The provider coded this as A49.8 Other bacterial infections of unspecified site. Of course, the code should be more specific.
Would you code this as:
L08.89 Other specified local infections of the skin and subcutaneous tissue, B96.5: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere?
If not, how would you code this?
2. Aside from Flu and COVID-19, when is it okay to code for a specific bacterial/viral/fungal infection without a definitive pathology report if the physician DOES state that that is the cause of the infection (e.g. no swab was taken)?
Thank you!