Bill an E/M level in addition to debridement with proper documentation
APCs Weekly Monitor, February 22, 2008
Want to receive articles like this one in your inbox? Subscribe to APCs Weekly Monitor!
QUESTION: A patient presents to a clinic for weekly wound care for multiple wound sites caused by vascular disease. A physician performs a partial thickness debridement on one site but does not perform debridement on any of the other sites. Is it appropriate to charge an E/M level in addition to the debridement?
ANSWER: Reporting an E/M level in addition to a code for the debridement is appropriate if the physician's documentation supports the fact that the E/M service is separate and distinctly identifiable from the debridement. Reporting an E/M level is also appropriate if the physician and/or staff documents that an additional service was provided in order to assess the nondebrided wound sites. If the hospital bills both a debridement procedure code and an E/M code, the APC payment will cover the facility expense for supplies, room use, and staff resources used during the procedure. Use your internal E/M facility policy to address these types of questions and to support your billing. Remember that your policy should adhere to the 11 Medicare E/M guidelines effective for 2008.
Want to receive articles like this one in your inbox? Subscribe to APCs Weekly Monitor!
Comments
0 comments on “Bill an E/M level in addition to debridement with proper documentation ”
Related Products
Most Popular
- Articles
-
- Q/A: Volume requirement for reporting hydration services
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- Catch up on what's new with injections and infusions
- Identify potential Medicaid RAC target areas
- HIPAA Q&A: Level of encryption needed for email
- Topic: CMS, OESS post new security compliance review information, checklist
- Capturing all necessary codes for IUD insertion and removal can be challenging
- What does case-mix index mean to you?
- OB services: Coding inside and outside of the package
- QA:Coding multiple initial infusions
- E-mailed
-
- Q/A: Volume requirement for reporting hydration services
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- HIPAA Q&A: Level of encryption needed for email
- Q&A: Follow CMS' coding guidelines when using modifier -25
- What does case-mix index mean to you?
- Catch up on what's new with injections and infusions
- CMS has reformulated payments for some bilateral procedures
- New conflicts of interest create new challenges
- Q/A. One injection code or two?
- ED-to-inpatient transfers are flawed with safety gaps
- Searched