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Q/A: Report E/M code when clinician evaluates separate complaint

APCs Insider, May 7, 2010

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Q: My question pertains to new CPT code 29581 (application of multi-layer venous wound compression system, below knee). May we also bill for E/M if we don’t charge for debridement or another billable procedure?

A: Every procedure includes some basic E/M. If the patient is scheduled for wound care, such as application of multi-layer venous wound compression system, the fee for the procedure includes evaluation of the patient for this issue. Submitting a separate E/M code for these routine evaluations performed at the same time as the scheduled wound care procedure is inappropriate. However, if the clinician evaluates the patient for a separate complaint at the time of the scheduled wound care office visit, submitting a separate E/M code with modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) is appropriate.

Because wound clinics are under close scrutiny by the Office of Inspector General and recovery audit contractor reviewers, clear documentation by the physicians and/or clinicians is essential. The clinic note must describe all services rendered to support medical necessity and code assignments submitted on the claim.

Editor’s note: This question and answer originally appeared in the May 2010 issue of our sister publication, APC Answer Letter.

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