E/M Generally Isn’t Separately Reported with Wound Care
Generally, wound care involves assessment and management of the wound, cleansing of the wound, simple debridement, and removal and reapplication of the wound dressings. In most cases, it is inappropriate to report an E/M service in addition to a wound care service (e.g., debridement, application of an Unna’s boot, etc.); however, if during the wound care encounter the provider performs a significant, separately identifiable service, and the provider documents this in the patient’s medical record, it may be appropriate to report an E/M service—with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended—in addition to a wound care service code. To be considered a significant, separately identifiable service, the reason for the E/M would need to be a condition or issue not related to the scheduled visit, and would require further medical evaluation and treatment.
- E/M Generally Isn’t Separately Reported with Wound Care - October 18, 2017