Orthopedic Coding Alert

Question: Our physician diagnosed a patient in the office with a necrotic hip pressure ulcer, debrided it and admitted the patient to the hospital on the same day for further operative management of this pressure ulcer. Can the office visit with debridement and the hospital admission be coded together?

North Carolina Subscriber
 
Answer: You can report an E/M service using the initial hospital care series (99221-99223) and a skin debridement code (11040-11044). The instructions that precede the initial hospital care codes state, "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital ED, observation status in a hospital, physician's office, nursing facility), all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission." Be sure to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.