Primary Care Coding Alert

Question: How should we bill for a visit that involves simple wound care when no debridement is involved? Our provider says that she usually spends up to 30 minutes with the patient performing dressing, irrigating and cleaning of the wound, as well as re-dressing.

Nebraska Subscriber

Answer: Simple wound care as you describe would be best represented with an evaluation and management (E/M) code. Because there is no debridement, a level-two or level-three office visit code would probably be most appropriate because the doctor or other provider spent about 30 minutes face-to-face with the patient.


- You Be the Coder and Reader Questions are answered and reviewed by Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Systems, a billing and coding firm that supports urology and family practice physicians in Broomfield, Colo.; Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City; Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians; and Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.