ED Coding and Reimbursement Alert

Question: I have a question about evaluation management levels for active wound care management. If a physician documents wound size, exudate etc. but does not perform debridement, how does assessment of wound affect evaluation management level? For example, is this considered part of the physical exam and would it be problem focused? I would think that any recommendations in regards to cleansing of wound etc. would be considered part of medical decision making.

New Hampshire Subscriber

Answer: There are a series of active wound management codes (97597-97606), but they would not typically be used in the ED setting. These codes are used to describe active wound care to remove devitalized or necrotic tissue and promote healing. They are much more typically provided in long term care settings for wound care of bed sores or diabetic foot problems by podiatrists. The active wound care codes require debridement or other removal of devitalized tissue.

While selective sharp debridement may be performed at the bedside in the ED occasionally, the modalities such as use of a high pressure water jet with/without suction are fairly uncommon. Absent clear documentation of one those functions being utilized, chose the appropriate E/M code for the site of service.

In the ED, the best code choice would likely be the ED E/M code that most closely matches the actual service performed. If the wound is closed after cleaning, perhaps a repair code would be indicated as well.