Documentation and correct coding question



For many months I've sent out training material to our group. Information about why ICD10 is important, how to look up codes, how to document and more. I've probably written over 70 pages worth of how-tos and other guides over the course of a 9 months.

As we get closer to October 1st, I've heard very little feedback from anyone in the office. Very few questions or acknowledgements...and ICD10 is a big change. I expected something. Obviously I'm a little worried.

I code in our office and am not worried about myself. I'm worried about our documentation.

Our EHR allows the staff to choose a description, if they choose a description that appears in the final office note under Assessment of "Pressure Ulcer, Stage 1, unspecified leg"...but their earlier exam shows that the pressure ulcer occurred on the right thigh....can I code based off of that? Or do I need to send those back to the provider for clarification since the Assessment the provider signed off on says "unspecified leg"?

I hope that question makes sense.