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Family Practice Coding Alert

Documentation Drives Proper Wound-Repair Coding

Minor and intermediate wound repair is a staple of many family practices: An 8-year-old boy falls off his bike on a dirt road, presenting with scrapes and several small lacerations; an elderly man slices open his forearm while using an electric hedge trimmer; a young woman sustains a long, shallow cut from a sharp edge on the aluminum bleachers at a local ball field.
      
Treatment for these and similar injuries may range from simple cleaning to debridement, to application of 2-octyl cyanoacrylate liquid adhesive (e.g., brand name Dermabond), to single or multilayered suturing. To optimize reimbursement, coders must understand several  codes and whether they are reported alone or with others.
Basic Coding Describes Simple Wound Care  
When family physicians treat cuts, scrapes or open wounds that require cleaning but no extensive treatment, an office visit (99201-99215) is charged. The services include application of topical antibiotics and dressings like steristrips or butterfly bandages.
 
If debris is removed from the wound, soft-tissue debridement codes (11040-11044) are assigned. According to Wendy Walker, CPC, coding and chart auditor for Central Penn Medical Group in East Petersburg, Pa., this series describes wound care provided by a physician using sterile technique. Foreign material and devitalized tissue are excised, antibiotics may be applied, and the injury dressed. CPT 11040 is defined as debridement; skin, partial thickness, while subsequent codes identify debridement of successively deeper wounds. Medications and bandages are included in the fee schedule for the code.
 
Most often, an outpatient E/M code would not be reported in addition to the debridement code, Walker says, because an injury requiring immediate care is usually the only reason for the visit. On those rare occasions when a patient is seen for a truly separate condition, both codes may be reported. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is appended to the E/M code. For example, if an 8-year-old boy fell from his bike on the morning of his annual checkup, the family practice may report the preventive office visit (e.g., 99393, periodic preventive medicine, established patient; late childhood [age 5 through 11 years]) with modifier -25, and 11041 (debridement; skin, full thickness) if time was spent cleaning the wound.
Documentation Needs To Be Detailed  
Walker says a lot of information must be processed in extensive wound-repair cases. Its important for coders to remind physicians that documentation must be very detailed to provide the information necessary for correct billing, she says.
 
She adds that when debridement and a repair are done together, coders should report only the relevant repair code because debridement is considered part of the overall service.
    
When more extensive wound repair requires staples, [...]