Wiki Wound Care

[kiku3@ptd.net]

I am new to this doctor and here is my problem: I have a surgeon who sees patients on an on-going basis for wound care, usually elderly with Medicare in an outpatient status at our hospital. My question is do I bill an E/M level and so he has to meet all the requirements of such for his notes, or is there something else I should be billing. He is only giving me a short history, sometimes a clinical exam, sometimes not and a very brief plan of what he is going to do, e.g. apply unna boot or treat with occlusive dressing. I have been telling him that there is insufficient documentation to even code, am I correct? Help I am pulling my hair out with him.

 

[FTessaBartels]

Without the notes ...

Without seeing the actual notes, it's hard to give you a definite answer.

However, with existing patient a brief history and a treatment plan may be sufficient to code a 99212 visit.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[kiku3@ptd.net]

Thank you, it does, but I guess my question really is this, am I supposed to be billing an E/M level ex. 99212-99214 with a dx code? That is how I have been coding these encounters, but someone questioned if I should be using a E/M level at all.

 

[solocoder]

Wouldn't it come down to medical necessity? Is there any new problem addressed at the visit? Or new way of treating the established problem? If not, there probably isn't a medical necessity for an e/m. I believe a very brief history and exam would be considered included with the staged or repeated procedure.