Health Information Management

Q/A: Proper coding for multiple wounds at different sites

APCs Insider, October 23, 2009

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Q: A patient with multiple wounds at different sites receives active wound management at one wound site, but receives different treatment for the other wounds. May we bill an active wound management code and an E/M level for the other area or areas?
A: The answer depends on what the physician ordered, what was performed, and what is documented for each wound.
Most FI/MACs have Local Coverage Determinations (LCD) that specify what providers must document to support the service that was rendered. Documentation requirements are very specific concerning the type of tissue present, type of tissue removed/treated, and the requirements for each method of treatment. NCCI edits also dictate code pairs that may be reported for the same date of service—even if multiple wound sites are present. For example, if a clinician performed a nonselective debridement on one wound and active management on another wound, then you may report only an active management CPT code (97597 or 97598). These codes are mutually exclusive with a CCI indicator of 0, which means you may never report them together during the same session or visit.
CMS has said that reporting an E/M code is inappropriate when a CPT code describes the service provided. (Refer to the Federal Register, November 24, 2006, for the Final Rule for CY 2007 OPPS.) For example, don’t report an E/M level when nonselective debridement is provided because CPT code 97602 describes the service.

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