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ED Coding and Reimbursement Alert

You Be the Coder:

Use Broken Skin As Clue to Proper Wound Dx

Published on Mon Jul 26, 2010

Question: A patient reports to the ED after suffering a dog bite on her right forearm; The ED physician performs a level-two E/M service, and then fixes the wound with a 2.8 cm repair using surgical staples. The wound depth extended "to the subcutaneous tissue," according to notes. Is this an open or closed wound, and which CPT code should I choose for this encounter?Michigan SubscriberAnswer: Since the patient's skin was broken, this is an open wound. On the claim, report the following:12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet; 2.6 cm to 7.5 cm]) for the wound repair99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ...) for the E/M servicemodifier 25 [...]
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