Eli's Rehab Report

You Be the Coder:

Is Wound Care Part of E/M?

Question: How should we bill for a visit for simple wound care with no debridement? Our physiatrist usually spends up to 15 minutes with the patient performing wound cleansing and redressing.

Indiana Subscriber

Answer: When the physiatrist performs simple wound care as you describe it, without any debridement, you should report an E/M code ( CPT 99201 - 99215 for outpatients). You should select the most accurate E/M code based on the elements present in the caregiver's examination of the patient.
 
The wound care codes (97601-97602) and the debridement codes (11040-11044) are reserved for true debridement services and should not be used for simple wound cleaning.