Dog bite -E/M MDM complexity w/procedure?

KRZollinger67

Contributor
Messages
12
Location
Columbia, SC
Best answers
0
Would love some feedback on what level of complexity you would code dog bites. Would you see this as a level 3 or 4 E/M in addition to the 12001 procedure that was fully documented?

Summary points:
Patient presents with 2.5 cm open wound closure measured on hand due to dog bite. Simple closure performed. Prophylactic ABX RX given.

Thanks!
 

csperoni

True Blue
Messages
1,974
Location
Selden
Best answers
3
All outpatient E/M visits are leveled by time or MDM (2 of 3 elements of problem, data, and risk).
A dog bite could be a scratch, a small puncture, a tear involving muscle or a life threatening condition.
Problem: could be straightfoward (level 2), low (level 3), moderate (level 4), or high (level 5).
Data: likely minimal or none (level 2). If tests were ordered, or independent historian, or discussion of management, it could be higher.
Risk: could be minimal (level 2), low (level 3), moderate (level 4), or high (level 5) depending on the tests and treatment plan.

With the very limited information you provide above, it does not seem like an E/M would be warranted with -25 as there is no significant and separately identifiable visit.
 

KRZollinger67

Contributor
Messages
12
Location
Columbia, SC
Best answers
0
All outpatient E/M visits are leveled by time or MDM (2 of 3 elements of problem, data, and risk).
A dog bite could be a scratch, a small puncture, a tear involving muscle or a life threatening condition.
Problem: could be straightfoward (level 2), low (level 3), moderate (level 4), or high (level 5).
Data: likely minimal or none (level 2). If tests were ordered, or independent historian, or discussion of management, it could be higher.
Risk: could be minimal (level 2), low (level 3), moderate (level 4), or high (level 5) depending on the tests and treatment plan.

With the very limited information you provide above, it does not seem like an E/M would be warranted with -25 as there is no significant and separately identifiable vis

Thank you for your time and response.
 
Top