Health Information Management

Tip of the Week: Watch for 'complications of care' that didn't occur

APCs Insider, June 29, 2007

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Physicians are very good at examining patients from the front. Not all physicians are good about looking at a patient's back, heels, or legs. Patients who are bedridden at any location for any reason can get skin holes that represent decubitus ulcers (patients can also get skin holes for many other reasons).

When someone identifies that a patient has a skin hole found on admission assessment (not a stage one decubitus--that's not an ulcer yet), the physician should provide a diagnosis for the lesion and, when it does represent a decubitus, attest that it existed prior to admission.

The physician must decide whether it is one of the following:

  • Arterial ulcer
  • Venous stasis ulcer
  • Diabetic skin ulcer (with or without osteomyelitis)
  • Open abscess, whatever the cause
  • Decubitus ulcer
  • (The above tip appeared in the July 2007 issue of Briefings on Coding Compliance Strategies).

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