• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
  • Important Note: We will be performing a scheduled maintenance on 1st November 2020. The site will be offline from 7:30PM (MT) till midnight. We apologize for any inconvenience this may cause.

Laterality

JCampbell

Guru
Messages
165
Best answers
0
If a provider states in the objective "great toe" but then states in the assessment "cellulitus of toe" is it appropriate to ask that they clarify by putting "great toe" in the assessment?

Also, if a nurse states in their intake where the cellulitus is located, is it necessary for the provider to state the locality in the assessment?

I think in both instances that it does need to be stated, but I do not want to ask for more from the provider if it is not necessary.

Thanks,
Jennifer
 

tag60

Guru
Messages
150
Best answers
0
For your first question--as long as it is documented in the note somewhere that it is the great toe, I see no problem with using that to be more specific in your diagnosis coding. I would not ask for that clarification in the assessment because it is already specified in the exam.

For your second question--here I would rely on the provider's documentation, not the nurse's intake statement. I've seen too many inconsistencies in this regard, and it's really up to the provider to document. Again, as long as I can find specific location documented somewhere in the note, I will use that.
 
Top