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Wiki PROCEDURE: Dressing Change, Dry, Sterile

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veloso

Expert
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262
Location
Beechhurst, NY
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Hi All,
Please advise if the provider is correct billing code 16020 with Op Report below;


Procedures
Wound Care:
Location: left , right distal legs.
Wound Care: wounds cleaned, sterile dressings applied.


EXTREMITIES:
Lower Extremities: both legs with deep leg ulcers above ankles, surrounded by darkening of skin. ulcers with soft yellow crust covering entire area. no surrounding erythema or edema unchanged from last visit - nursing provided wound care with sterile wet to dry dressing after cleaning wounds.



Assessments
1. Ulcer of ankle, unspecified laterality, unspecified ulcer stage - L97.309 (Primary)
Thank you!
 
0
16020 is incorrect. If you read the description of the CPT, you’ll see that this code is for care of burns. The documentation you’ve shared doesn’t mention that this wound was a burn.
 
0
When I worked in wound care, dressing changes were inclusive to E&M services. I’m not aware of anything that’s changed for this, though I’m not current on the latest CPT updates.
 
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