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Tetanus Vaccine/Open Wound - notes in the documentation

  1. #1
    Overland Park, KS
    Question Tetanus Vaccine/Open Wound - notes in the documentation
    Medical Coding Books
    I have a dilema that I hope someone can provide some insight on, please....

    A patient presented to one of our clinics with a dog bite. The provider (NP) notes in the documentation that the wound was healing well, and then administered a tetanus vaccine to this patient. The provider did not code the open wound, she just coded the V code for the vaccine using the rationele that she did not treat the wound, she only administered the vaccine.

    My questions are:

    1. What actally consitutes "treatment" of a wound per Medicare in order to administer a tetanus vaccine? Is administering the vaccine only considered "treatment?"

    2. Is there any criteria as to what actually constitues an evaluation of a wound? I realize that inspection of the skin is an element in E/M, but is just stating that the patient has a wound and it appears to be healing well enough to justify a tetanus vaccine to Medicare?

    I hope my questions make sense and someone can provide insight. Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  2. Red face
    There has to be an open wound for medicare to pay for it.
    Hope this helps!

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