Health Information Management

Bill an E/M level in addition to debridement with proper documentation

APCs Insider, February 22, 2008

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

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 Insider!

Comments

0 comments on “Bill an E/M level in addition to debridement with proper documentation

 

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular