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How can this be coded?

  1. #1
    Question How can this be coded?
    Medical Coding Books
    We had a patient who wrecked on her 4 wheeler. She came in repeatedly to have the wound checked to and on one visit she saw our nurse who has a Masters in Wound Care. She cleaned the wound with normal saline and removed 2 foreign bodies (wood splinters) with tweezers. How can this be coded?

  2. #2
    Dover Seacoast New Hampshire
    FB removal includes an incision, not just picking out debris with tweezers. Wound care guidelines are very specific, so it doesn't matter if your nurse is a wound care expert, it matters what she actually did. Those wound care codes include selective excisional debridement down to deeper levels of skin and subcutaneous tissue, muscle and/or bone, so what you are describing is not wound care for the purposes of the codes in the integumentary and medicine sections of CPT.

    Basically, (without seeing the note), I'd simply bill an E&M visit, unless you're bumping up any other 10-day global procedures that you haven't mentioned.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3
    I noted that in your post, you mentioned that the patient was seen by a nurse. If this is not a nurse practitioner and the physician was not present, then you can only code 99211

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