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Thread: Wound Care

  1. #1

    Unhappy Wound Care

    AAPC: Back to School
    I am new to this doctor and here is my problem: I have a surgeon who sees patients on an on-going basis for wound care, usually elderly with Medicare in an outpatient status at our hospital. My question is do I bill an E/M level and so he has to meet all the requirements of such for his notes, or is there something else I should be billing. He is only giving me a short history, sometimes a clinical exam, sometimes not and a very brief plan of what he is going to do, e.g. apply unna boot or treat with occlusive dressing. I have been telling him that there is insufficient documentation to even code, am I correct? Help I am pulling my hair out with him.

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Without the notes ...

    Without seeing the actual notes, it's hard to give you a definite answer.

    However, with existing patient a brief history and a treatment plan may be sufficient to code a 99212 visit.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3


    Thank you, it does, but I guess my question really is this, am I supposed to be billing an E/M level ex. 99212-99214 with a dx code? That is how I have been coding these encounters, but someone questioned if I should be using a E/M level at all.

  4. #4
    Join Date
    Apr 2007
    Springfield, Mo


    Wouldn't it come down to medical necessity? Is there any new problem addressed at the visit? Or new way of treating the established problem? If not, there probably isn't a medical necessity for an e/m. I believe a very brief history and exam would be considered included with the staged or repeated procedure.

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