Primary Care Coding Alert

Question: Our physician treated a new patient with a pressure ulcer on the back of her head. After performing a level-two E/M service, the physician diagnosed the ulcer, then performed partial-thickness debridement on the wound. How should I report this encounter?


Mississippi Subscriber

Answer: You-ll be able to code for an E/M and a debridement in this instance:

- 11040 (Debridement; skin, partial thickness) for the debridement

- 707.09 (Decubitus ulcer; other site) attached to 11040 to represent the patient's ulcer

- 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making) for the E/M service

- 707.09 linked to 99202 to represent the patient's ulcer

- modifier 25 (Significant, separately identifiable  E/M service by the same physician on the same day of the procedure or other service) appended to 99202 to show that the E/M was a  significant and separately identifiable service from the debridement.

Remember: In this scenario, you can use 707.09 as the diagnosis for both CPT codes. If the physician performs an E/M and a procedure for the same problem, you can report the same diagnosis code for both. Regarding this type of scenario, CPT states, -different diagnoses are not required for the reporting of the procedure and the E/M service on the same date.-    

Although correct by CPT standards, be aware that some payers may have reimbursement edits that look for a second or different diagnosis.