heatherwinters
Expert
I work for an FQHC. A patient came in for evaluation of a bulla that had started to drain that day. Our PA documented 1 HPI, 1 ROS and the documentation in history of coexisting conditions.
Provider performed problem focused exam - Vitals - General - Skin. He documented size of bulla, discharge, no surrounding erythema or induration and no lymphangitis streaking.
Documentation of procedure indicates prepping with betadine, and "bulla debrided of overlying devitalized skin". He documented base replete with granulation tissue then dressed with silvadene, telfa, gauze with Kling overwrap and gave prescriptions for antibiotic and dressing supplies.
Wound Culture was obtained.
He wants to bill 97597 however, without documentation of instrumentation or method of debridement I am wondering if an E/M is more appropriate. He had not previously assessed this condition. Thoughts anyone?
Provider performed problem focused exam - Vitals - General - Skin. He documented size of bulla, discharge, no surrounding erythema or induration and no lymphangitis streaking.
Documentation of procedure indicates prepping with betadine, and "bulla debrided of overlying devitalized skin". He documented base replete with granulation tissue then dressed with silvadene, telfa, gauze with Kling overwrap and gave prescriptions for antibiotic and dressing supplies.
Wound Culture was obtained.
He wants to bill 97597 however, without documentation of instrumentation or method of debridement I am wondering if an E/M is more appropriate. He had not previously assessed this condition. Thoughts anyone?
