Documentation Dissection - AAPC

[Pages:1]Documentation Dissection

Skilled Nursing Facility Subjective:

1. E dema: Pt has hx of CAD, MVP and tricuspid insufficiency. I started pt on Lasiz and her edema and leg swelling is better. PT feels good. No F/C, N/V, or chest pains.

2. Hypertension is under control with new drug prescribed couple weeks ago. 3. Pressure Ulcer: On coccyx. Healing well. Wound care nurse is on board. Assessment and Plan: 1. Edema |1|: Seems to be due to CHF |2| as pt has history of CAD. Continue Lasix to 20 mg BID. KCL. Normal BMP. Ace wrap.

Monitor. Consider Echo-cardiogram as outpatient basis. Incentive spirometry. 2. HTN |3|: Continue Irbesartan and monitor. 3. Pressure ulcer |4|: Stage 2 |5| on coccyx |6|. Duoderm and hydrogel. Wound care nurse is on board. Per nurse wound is almost healed. _____________________________________________________________ |1| Primary diagnosis is edema without further specification. |2| This is not considered definitive and is therefore not reported. |3| HTN is an abbreviation for hypertension. The hypertension is not specified as acute or chronic. |4| Type of ulcer. |5| Stage of the ulcer. |6| Location of the ulcer. _____________________________________________________________ What ICD-10-CM code(s) is/are reported? ICD-10-CM Codes: R60.9, I10, L89.152 Rationale: The patient has edema, hypertension, and a pressure ulcer on the coccyx. Look in the ICD-10-CM Alphabetic Index for Edema R60.9. Verify code selection in the Tabular List. Next, look in the Alphabetic Index for Hypertension I10. Verify code selection in the Tabular List. Look in the Alphabetic Index for Ulcer/pressure/stage 2/coccyx L89.15-. In the Tabular List, 2 is selected for the sixth character to indicate stage 2.

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