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Evaluation management level wound care

Bonnie Posted Thu 28th of March, 2013 01:56:19 AM

I have a question in regards to evaluation management levels as they pertain to active wound care management. If a physician documents wound size, exudate etc but does not perform debridement, how does assessment of wound affect evaluation management level, for example is this considered part of the physical exam and would be problem focused? I would think that any recommendations in regards to cleansing of wound etc would be considered part of medical decision making.
Thanks so much

SuperCoder Answered Mon 01st of April, 2013 21:24:30 PM

There are a series of active wound management codes (97597-97606).These codes are used to describe active wound care to remove devitalized or necrotic tissue and promote healing. They are much more typically provided in long term care settings for wound care. My understanding of the active wound care codes is that they do require debridement or other removal of devitalized tissue. Absent those functions being documented, chose the appropriate E/M code for the site of service.

In the ED, the best code choice would be the ED E/M code that most closely matches the actual service performed. If the wound is closed after cleaning, perhaps a repair code would be indicated as well.

SuperCoder Answered Tue 02nd of April, 2013 00:46:51 AM

I agree that I would count the wound assessment part of the exam. If the skin is the only system examined, you could have a problem focused exam per 1995 EM Guidelines. The level could be higher if other system are reviewed and documented provided there is medical necessity to support performing them.

I would also count the management option such as cleansing as part of the medical decision making. If the physician then proceeds with debridement or another procedure, a separate paragraph for the procedure will help show that the wound exam and treatment decision are part of the significant, separately identifiable evaluation and management service indicated with modifier 25 on the EM code. Once debridement or wound care become standing orders, then no EM-25 would be billed unless a change in the wound or another condition requires evaluation and management.

Jen Godreau, CPC, CPMA, CPEDC

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