Primary Care Coding Alert

Context key for correct procedure, Dx documentation.

A 35-year-old patient reports to your provider after stepping on a rusty nail two days before. Your provider notes an open 1.2 cm wound on the patient’s left foot and performs a simple closure. The physician checks the patient’s records and notes that the patient last received a tetanus shot over ten years ago. Your provider decides to administer a tetanus booster to the patient.

How would you code this case study?

Coding the Encounter

The first problem confronting coders in this scenario involves whether to code for a separate evaluation and management (E/M) service or not.

“If this were a new patient, a separate E/M would be appropriate as the provider would have no knowledge of other health issues prior to making the decision to do the surgery,” advises Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico. Because of this, some payers may reimburse for a new-patient E/M from 99201 through 99205 (Office or other outpatient visit for the evaluation and management of a new patient …) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to indicate that the E/M service is separate and significant.

You can also make a similar case for coding a low-level established-patient E/M. “For medical necessity, the provider needs to determine if the wound just needs to be cleaned and bandaged or needs suture,” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “Also, the provider needs to assess if the patient has been properly vaccinated against tetanus and if there is any infection in the foot as it has already been two days,” Holle elaborates. So, providing the documentation in the medical record clearly supports that the provider did the work associated with an E/M service over and above the work associated with repair of the wound, you can report an established patient E/M service (e.g. 99212) with modifier 25 appended.

Coding the Procedure

You would report 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less) for the simple laceration. If the patient was enrolled in Medicare, and the simple repair involved your provider using Dermabond, you would use HCPCS code G0168 (Wound closure utilizing tissue adhesive[s] only) instead. Per CPT®, you should code a wound closure using adhesive strips only with the appropriate E/M code rather than a wound repair code.

Coding caution: “G0168 is considered a packaged supply code with the proper laceration repair codes and cannot be billed separately,” Holle notes. This is because the CPT® codes for wound closure include using sutures, staples, or tissue adhesives, either singly or in combination with each other, or in combination with adhesive strips. “Although there will not be a payment for the G code, you should still bill it so that they know it is a packaged supply,” Holle adds.

Coding the Immunization

Here, again, you may have a choice of codes depending on your provider’s notes. “Since inadequate protection against diphtheria and tetanus often occur together, Td is the preferred vaccine, not the tetanus toxoid alone” reports Witt. “It was for this reason that CPT^® deleted 90703 [Tetanus toxoid adsorbed, for intramuscular use] in 2016” Witt reminds coders.

This means that as the patient is over the age of 7, one of two vaccine products would apply here:

• 90714 — Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use
• 90715 — Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use.

“The Tdap, which includes vaccination for whooping cough, should be used in place of Td in patients who have an indication. The other tetanus-containing vaccines would only be given if the patient needed immunization against the flu, polio, or hepatitis B at the time of the injury,” Witt advises.

Additionally, you would also use 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)) for the vaccine administration.

Code the Dx

Here, you also have many choices. Depending on the kind of wound your provider reports, you could code S91.332A (Puncture wound without foreign body, left foot, initial encounter) or S91.312A (Laceration without » foreign body, left foot, initial encounter) from Chapter 19. Per that chapter’s Code Also note, you should use secondary codes from Chapter 20, such as W45.0XXA (Nail entering through skin, initial encounter) and/or Y93.01 (Activity, walking, marching and hiking).

You may also have to code any wound infection should your provider’s notes indicate it, as the S91 codes come with Code Also instructions for you to do so.

Guideline note: “Per ICD-10 guidelines, you would only use external cause codes if your provider ‘is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer’ as ‘there is no national requirement for mandatory ICD-10 external cause code reporting,” Witt advises.

Lastly, you would code Z23 (Encounter for immunization). This would not be listed as a primary diagnosis in this encounter, and it must be accompanied by procedure codes that identify “the actual administration of the injection and the types of immunizations given,” per ICD-10 guidelines.