Wiki Traumatic ulcer

[FractalMind]

Hi!

"Buttock ulcer due to patient's fall in bathtub...patient undergoing wound care"

I assigned: 707.8, 877.1

Is this accurate?

 

[mitchellde]

I would not use those codes as it does not tell the story. If the injury happened in the past and the ulcer has now developed as a result of the fall the you need the ulcer code and late effect of injury code (905-908). But it is hard to tell without the complete note..

 

[FractalMind]

Yea...this is only a home visit form and that is practically it...only the "ulcer is present" box is check marked, the rest is only a notation on the side...

So should I only code 707.8 then?

 

[mitchellde]

are you coding for home health or the physician?
I ask because if you are coding for the physician you cannot use a form as a means of providing you with information for coding purposes.
This is the statement is from the CMS transmittal on E&M coding:
Certificates of Medical Necessity (CMN), DME Information Forms (DIF), supplier prepared statements and physician attestations by themselves do NOT provide sufficient documentation of medical necessity, even if signed by the signed by the ordering physician.
These types of documents will NOT be considered when making a coverage/coding determination.

You will need the documentation from the visit to determine the correct code(s).