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Primary Care Coding Alert

READER QUESTIONS:

Remember to Represent Pressure Ulcer's Stage

Published on Fri Jan 01, 2010

Question: An established elderly patient reports to the family physician (FP) for inspection of sores on her back. The FP diagnoses a stage I pressure ulcer on her lower back. The FP refers the patient to a dermatologist for treatment of the ulcer after a level-three E/M. How should I report this diagnosis? Indiana Subscriber Answer: You should submit a pair of codes; one to represent the stage of the pressure ulcer, and another for the ulcer itself. On the claim, report the following: • 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of 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; • 707.03 (Pressure ulcer; lower back) appended to 99213 to represent the pressure ulcer; and • 707.21 (Pressure ulcer [...]
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