ED Coding and Reimbursement Alert

Question: A father brings his 6-year-old son into the ED after the boy suffered a bicycle accident: he fell off his bike, and sustained pavement burns on his right forearm. During an expanded focused history and examination, the physician performs several cognitive tests to ensure the patient did not suffer any neurological damage. The physician also orders a forearm Xray, which reveals no fracture. The physician then uses pickup forceps, a scalpel and tweezers to remove several pieces of small gravel from the wound and debrides devitalized skin; notes indicate that the debridement was "mostly dermal." The physician then discharges the boy with a prescription for pain medication and instructions to follow up with his pediatrician in two weeks. Notes indicate moderate medical decision making during the encounter. Is this a simple or complex debridement?Montana SubscriberAnswer: In your scenario, the physician provided simple debridement service. On the claim, report the [...]