ED Coding and Reimbursement Alert

Question: A patient presented with a leg abscess, which the physician drained and packed. The patient returned two days later for evaluation of the wound, and the physician removed the original packing, irrigated the wound and placed new packing. How should I bill this? Can I report the two visits separately, or is the follow-up included in the original code?

Ohio Subscriber
 
Answer: When considering postprocedure follow-up visits, you must meet certain criteria in order to bill an E/M code. Code the initial draining and packing with 10061 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; complicated or multiple). There is no CPT code that accurately represents repacking a wound two days later. However, there are certain billable E/M services associated with the second visit you describe.
 
Your first step should be to decide whether the physician performed a complete E/M service during the second visit. Code 10061 is used on many wounds that require draining and packing. In accordance with the CPT rules regarding the surgical package, this code bundles "typical postoperative follow-up care."
 
But does this type of repacking represent "typical" post-op care? Follow-up evaluation and repeat packing are not assumed for all 10061 visits. Most often in a follow-up visit, a clinician is monitoring the healing process and removing the initial packing, and the patient is then discharged. Irrigation and repacking the wound is not typically required. So an E/M code may be what you need to represent your physician's services.
 
Before billing this visit, talk with your doctors and build a consensus about whether repacking a wound two days after the initial procedure is indeed standard post-op care.