Health Information Management

Q/A: May we bill an E/M code for a wound care first visit

APCs Insider, November 6, 2009

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Q.  Several of our facilities that include hospital-based outpatient wound care clinics have requested guidance in the following scenario.
A patient arrives at the clinic with a physician order for wound debridement. This is the patient’s first visit, and the patient meets the CPT new patient definition. The nurse performs the debridement and documents a history and physical.
Because this is a first visit, may we bill for an E/M level and the debridement? Should we bill only for the debridement in subsequent visits?
A. Medicare “incident to” guidelines for hospitals state that nurses must carry out orders from treating physicians and not add to or take away from any order. Just because the patient presents for an initial visit, you may not automatically report an E/M service.
In this case, the answer depends on how the physician ordered the first wound care visit. If the physician order is for wound debridement only, the hospital should bill for wound debridement. Bill the services described with one of the wound management codes—97597, 97598, or 97602. Each of these CPT codes’ descriptors includes the term “wound assessment” so wound evaluation is included when reporting the documented procedure.
After assessing the patient’s presenting condition, the wound care nurse might think that additional services are necessary or that a new issue has arisen since the patient saw the physician. In either situation, the wound care nurse should contact the ordering physician to determine whether further or different medically necessary services are indicated. You may bill an E/M service in addition to the wound care service only if it represents a medically necessary, significant, separately identifiable service ordered by the treating physician and provided by the hospital.

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