E/M Generally Isn’t Separately Reported with Wound Care

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  • October 18, 2017
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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.

Evaluation and Management – CEMC

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Barbara Aung, DPM, CWS, CPMA, CSFAC, has been in private practice for 22 years, where she also conducts clinical research in the field of wound healing and podiatric surgery. She serves on the American Podiatric Medical Association’s Coding Committee. Aung is a Panel Physician at Carondelet St. Mary’s Wound and Hyperbaric Center in Tucson, Ariz., a Healogic’s Managed Facility. She is vice president of the Tucson, Ariz., local chapter.

No Responses to “E/M Generally Isn’t Separately Reported with Wound Care”

  1. Toni Turner says:

    I think it’s important to clarify that the E/M service described in this post is one that would be provided by a physician or advanced level professional provider not an outpatient wound clinic visit reported by an institution. . The components that contribute to a facility clinic visit are not comprised of history, medical decision and exam like the physician E/M but continue to be based on resource use. That being said, in order for a facility to report a clinic visit with a 25 modifier in addition to a procedure done in the same encounter, the medical record must clearly reflect separately identifiable “resources” used in addition to those which are normally considered part of the pre and post procedure services. An example of this in an outpatient wound clinic: when a patient has multiple wounds that are assessed, cleaned, measured and specialty care dressings applied yet a selective debridement was only performed on one of the wounds. The resources used on areas that were not involved with the procedure and had been documented would warrant use of the 25 modifier with the facility clinic visit.