# Wound care coding-I have an outpatient



## becka95

I have an outpatient wound care clinic that we are in a tug of war over coding. Unfortunately, I am having a hard time finding solid, clear resources to reference. 

When that patient comes into the clinic for a wound care follow up and the Dr orders an application of a multilayer wrap, can the Dr bill an E&M plus the application of the wrap? I am under the impression that if he doesn't note that he supervised or personally put on the wrap then you can't. This is the same for wound Vacs and unna boots. 

I currently code for the facility side except for this one. I know that 29581, 29580 and 97605-06 are on the physician fee schedule but don't they have to document this? The hospital who does the Dr billing states that they can bill it for the Dr because he wrote the order. 

The hospital coders want all the CPT's to mirror each other (facility and professional) and I explained to them that this is not always possible because a facility E&M is calculated differently then a professional E&M. 

So in addition to my above question about billing for the dressings for the Dr without documentation that he supervised, does anyone have any links or references that they can share? I would greatly appreciate it!


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## newmy9

If the reason for the visit is wound care/dressing change and no other services are provided (ie prescription management etc) the E&M is included in the wound care. There has to be a seperate reason to charge an E&M.


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## becka95

I did explain the E&M and reviewed the modifier 25 but they are insisting that he needs to bill a 25 and a 29580, 29581, 29445 etc... 

His notes don't normally support the E&M with 25 but they are insisting that we have to bill it. I have given them the coding guidelines for E&M as well as wound care and our disagreement is interpertation of what is separately identifiable E&M. I said my rule of thumb is if there is worsening of the wound or major changes, new problems or a change in the course of treatment due to the current condition of the wound. They say any time the Dr sees a patient there should be an E&M unless there is a debridement.


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## lmartien

*Assoc. Director of Reimbursement Operations - Midwest*

Becka - I have been working in wound care for 10 years and this continues to be an issue with some providers.  If a patient presents for a specific purpose (the multi layer compression wrap, for instance), then only that service would be billed.  Unless documented, there is no apparent separate and identifiable E/M service provided.  I can't be absolutely sure from your scenario, but did the doctor actually see this patient?  In most wound centers or offices, in this type of circumstance, the nurse applies the compression wrap.  So, unless the doctor sees the patient, there would be no E/M charges as there is no face to face encounter.  Even 99211 would not be billed as the nursing service is not separate and identifiable.

As for your second question about billing the Unna boot, compression wrap or selective debridement, the fact that there is an order on file doesn't mean it was done.  It falls back on the old rule, "if it isn't documented, it wasn't done."  I agree with you on this!

You are again correct in the E/M levels in the facility vs. the professional compoenent.  Different methodologies are used so they will not always mirror each other.  I do have the original OPPS rule (April 2000) where the faclity E/M criteria is listed.  I also have an exmaple of a wound center E/M leveling tool if you would like to see it.  You can contact me at lmartien@shire.com.


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## deborahcook4040

*Physician coder,billing for the facility *

I would not normally bill for a TCC for my physician unless it was clearly documented that he put the cast on himself. On a similar note: I've been asked to do the facility coding while we're in-between coders (probably until March 2014), even though I am only trained in physician coding (because my physician is employed by the facility, and so am I and neither of us can refuse).

On those few occasions where the physician does clearly apply the cast himself, what do I bill for the facility? an E&M? If I don't bill a 29445, are we still going to get paid for the materials?


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## woundokc

When a strapping or unna boot is put on by the staff the visit is bundled into this service.  The physician would only be able to charge for the strapping or boot if he put it on himself.  
If the physician did see her on that day he could charge for an E&M but not a strapping or a unna boot.
As far as the CPT codes mirroring each other.  They will only mirror on the procedures not including the vacs, strapping or unna boot codes.  They should mirror on the debridements.  The E&Ms have not mirrored each other in the past but now that we only have one E&M I guess they will from now on.  An E&M should not be charged unless it meets the 25 modifier rule of a new problem when a procedure is done.


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## mjstack

2020: I have a similar scenario that is evolving. I code for Doctor HMA portion of a facility based wound care center, for the past 3 years. I do not automatically bill the 99211//2 for a "nurse" that is assigned to the travelsheet, but review each visit on a note by note case to see if there is a new or significant issue that has the reason to cause an exam to be needed (medically necessary). Most times there is, but when the doctor has re-evaluated on say monday and the plan of care is to come back on weds and friday for bandaging or other nurse attending services, the doctor is expecting to bill a 99211 because she is in the building. Can anybody point me to an official something so I can provide proof? thank you


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## thomas7331

Our local Medicare contractor (NGS) has published a good job aid on the use of 99211 which I recommend as a very helpful tool for determining when this code is appropriate:



			https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/job-aids-manuals/procedure%20code%2099211%20job%20aid/!ut/p/z1/vVTLcpswFP0Vd-ElI4F4aSnzsDHFhLpuDBsPAUGUgCAYO22_viLjmabOBNeTTrXRCJ17ju7jABKwBQlPj6xMe9bwtBLnONF3KvEcWbagH5oLCIlvE5Ws5kjVEbg9A6DQhER1Z7Yd3aD5TAHJ62vTQzoklot8Bc1kzTNO8fCdReDfxf_Wtxwi9O2VviKuHELt2vg_EgzX1-q_BSTj9fsGEpC0GctBjJTMyAukSZhCTVIVI5UwzHMJZwVWZYyxmSsDOuN929-DmJf7muYsSzuaNbynvOf0eQpffX45913KOOPlFD40d5OU5ftJnfJDWu2nsO2ajOaHjk6yJqcTjBVZnpxg46UZ3p6Md-52eOyF4bjEkYzV76U9Z4A3_Y9FFsZOx4E3x6ayMjeRCSNv6eCbpZAIIVgPHKxuK5axPhBlqEDcdwd6inwvf1ckeGT0GWx409XCKusrO7mAFxQc-YMKZ_TQ9pGgN8KFDyMEdf0f088ifaB3kWfacG4YH6RfXrKO-DcpXWAFpaBN-3uJ8aIB29GRFiHs4ekpIcJFg2W-92D7P2w0OoBtvRlWbaIf0uOXxc-vRW3dmYGDtLLeDVt1_Fw8kk-_AD8kOXg!/dz/d5/L3dHQSEvUUtRZy9nQSEh/#Z7_69MIG982N8UQ80QIJE9PJ000O0


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## MatthewSchweyer

I've a question when a patient present to the wound center has multiple ulcers, some are debrided and others are not.  However the ulcers that were not debrided had a vull assessment for that visit performed including measurements, review of Plan of Care, etc.  In this scenario is it appropriate to bill bothe the 11XXX and the E&M code?  If so, should the E&M be amended with modifier 25?


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