Primary Care Coding Alert

Question: After evaluating an established patient's varicose leg ulcer, the family physician (FP) applied an Unna boot. Which CPT codes should I use?

Maryland Subscriber

Answer: You should report 29580 for the Unna boot application (Strapping; Unna boot). To indicate that the FP provided a significant, separately identifiable E/M service from the Unna boot application, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service ...) to the office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...). When the patient returns for reapplication, don't report an E/M service unless the FP treats a different problem, such as a cold (460).