Linking wound to surgery

Linda_RhodesLinda_Rhodes
in CDI Talk Archive
This question came up recently in a coding/CDI discussion at our facility. I am hoping to get some feedback from the group.

Pt admitted for "non-healing wound". MD documents in H&P: non-healing wound, s/p toe amputation. Pt also has DM and PVD.
Does the use of "s/p" assume a link between the wound and surgery? In other words , would you automatically take this to 998.3- non-healing surgical wound without a query?

I appreciate your comments.
Thanks,
Linda


Linda Rhodes RN, BSN, CCDS
Manager Clinical Documentation Improvement
New Hanover Regional Medical Center
Wilmington, North Carolina
Office # 910-815-5544
Cell " 910-777-8344
e-mail : linda.rhodes@nhrmc.org

Comments

  • kmaritankmaritan
    edited May 2016
    Per our coders poss 998.83 with no query needed, the link is "s/p toe amputation". However, they said these cases can be tough. Could possibly be a stump complication even after an amputated toe.

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I believe our coders would take it without a query. I think "non-healing wound, s/p toe amputation." Is a decent link.

    Katy Good, RN, BSN, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

  • Unknown
    edited May 2016
    If it's a complication code I always query the physician for complication vs expected event.

    Tracey Carey RN
    Clinical Documentation Specialist
    686-7421
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