Health Information Management

Tip of the week: Although assessment is an integral part of all wound care services, do not report separately with E/M

APCs Insider, April 25, 2008

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Under the OPPS, when a patient presents for a scheduled procedure (e.g., wound care debridement), the hospital should report the CPT code that describes the procedure the physician performs.

Physician documentation is essential to this process. The debridement code that the hospital reports should reflect the type and amount of tissue removed during the procedure and the depth, size, or other characteristics of the wound. In circumstances in which there is no applicable HCPCS code to describe the distinct service, report the most appropriate unlisted procedure code.

Assessments of the wound are an integral part of all wound care services codes. Therefore, you cannot separately report assessments using an E/M code.

A facility may report a separate clinic E/M level only if the hospital provides a significant, identifiable visit that is separate from any other service provided. This general rule applies to any service provided by a hospital.

It would be appropriate to report a separate E/M code for an initial patient visit and a wound assessment that results in a decision for an intervention. The E/M code the hospital reports must be based on the facility’s internal E/M guidelines. Hospitals must design their E/M guidelines to reasonably relate the intensity of the hospital resources to the different levels of effort represented by the CPT codes.

(The above tip was excerpted from the April issue of APC Answer Letter)



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