Question: How should we bill for a visit that involves simple wound care when no debridement is involved? Our physiatrist usually spends up to 30 minutes with the patient performing dressing, irrigating and cleaning of the wound, as well as re-dressing.
Answer: Simple wound care as you describe would be best represented with an evaluation and management (E/M) code. If the nurse performed the debridement, bill with 99212 (office or other outpatient visit for the evaluation and management of an established patient). Otherwise, choose the most accurate E/M code based on the elements present in the caregivers examination of the patient.