amputation levels - High, Mid, Low documentation requirements
We are wondering what others are practicing regarding below knee amputations and the documentation specificity of high, mid and low. If the MDs do not specifically document high, mid or low, but indicate a point of incision XXX cm from the tibial tuberosity can it be indicative and coded high mid or low based on the distance documented?
a few considerations -- the patient tibial length overall may not allow an assumption to indicate appropriately weather it is high, mid or low.
We know we should query MDs to specify the root operation in terms for coding -- but this is a different level of definition.
Any input is appreciated - thank you
Tagged:
Comments
Hi Jennifer,
The provider is not expected to use the terms high/mid/low. It is the role of the coder/cdi to interpret their documentation of the incision site into the correct code assignment. CCQ22017p3 provides some additional direction/assistance with this.
thank you Katie - nice to hear from you and hope all is well. We have looked at this reference but find that it has all anatomic locations described except the lower leg which is where we find it problematic.
We are going to work with our surgeons to ensure a consensus appreciation of their anatomic descriptions of the amputation and what should be equivalent for High, Mid and Low
Hi there!
Yes, I think the guidance would be the same. for A BKA, the Midshaft region would be mid, distal would be low, and proximal would be high. So I would select High for a amputation near the tibial tuberosity. However, if there is concern that it is unclear whether it is approaching mid-shaft (in this case), a query would be prudent.
Katy