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General Surgery Coding Alert

Reader Question:

Normal Evaluation Included in Wound Closure

Published on Thu Nov 01, 2001

Question: Can I bill separately for E/M services and wound closure if the E/M service is limited to the affected area?

Idaho Subscriber  
Answer: No. Any E/M services in the affected area are included in the wound repair. If the patient came in with a laceration on the arm and a separate problem (for example, a head injury), an appropriate E/M service could be billed to Medicare if the documentation indicates that more than a level-one visit, i.e., 99211, was performed. However, if the patient is being seen for the laceration only, the repair is all that should be billed.
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