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Dermatology Coding Alert

You Be the Coder:

Coding Open Wounds vs. E/M Services

Question: What is the difference between an open and closed wound, and does open wound treatment automatically mean you can choose a procedure code?

New York Subscriber

Answer: An open wound occurs when the skin is cut, torn, or punctured. The most common types of open wounds are abrasion, avulsion, incision, laceration, and puncture. If you see any of these terms in the notes, and evidence that the skin was breached, your provider might have performed open wound treatment.

Closed wound example: An established patient reports to the physician’s office with a badly bruised forearm. Another example could be a broken bone that doesn’t break the skin.

Open wound example: An established patient reports to the physician’s office with a badly bruised forearm. The patient also suffered several abrasions to the bruised area, a puncture wound, and impaction of bits of sand in the wound.

Open wound treatment does not automatically mean a procedure code, however. Some superficial open wounds will only qualify as E/M services.

Do this: Check the notes for the closure method. CPT® typically considers the following techniques as qualifying for wound closure coding: sutures, staples, or tissue adhesives. The physician might use one or a combination of these techniques to perform a wound repair service that you might code for a procedure. In fact, if the physician doesn’t indicate an open wound, you must assume it is a closed wound in most instances.

For example, if notes indicate that the physician used staples and sutures to close a patient’s 2.1 cm superficial neck wound, you’d report 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) for the repair.

If the provider closed a wound with only adhesive strips, however, you would report a code from the 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) to 99215 (Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity…) code set for the repair.