Pertinent Insights On Coding For Wound Care

Clinical Editor: Kazu Suzuki, DPM, CWS

Providing salient examples and insights from their experience, the expert panelists discuss proper documentation, coding for E&M services and appropriate use of modifiers.


What is the key to proper coding and documentation in wound care practices?


As Harry Goldsmith, DPM, emphasizes, proper documentation allows the wound care specialist and others treating the patient to evaluate the patient’s status continuously, and plan for and execute the appropriate treatments.

   “While serious wound care specialists are committed to excellence in wound care, they also need to understand and appreciate that quality documentation goes hand in hand with quality care,” says Dr. Goldsmith, adding that such thoroughness takes time.

   As the “captain of the ship” when it comes to submitting claims for reimbursement, the wound care specialist is ultimately accountable for accurate coding and billing for the services and procedures he or she performs.

   Kazu Suzuki, DPM, CWS, concurs, saying “you should code (and bill for) what you did, nothing more or nothing less.” He has heard that many physicians actually “under-code” their procedures because they have an unfounded belief that they are “over-billing” for their services and are afraid of being audited. On the other hand, he notes that “up-coding” or billing for more than what your service has provided is “a cardinal sin,” and can lead to severe penalties or prosecution.

   Dr. Suzuki strives for the best documentation possible with the assumption that every chart will be audited. He also takes multiple digital pictures (before, during and after) of surgical procedures as well as the specimens he removed to “tell the story” of what he performed.

   Anthony Poggio, DPM, says one must list the basics such as drainage, odor and cellulitis/abscess. He says it is also key to measure the wound before and after debridement, and describe the wound base. Dr. Poggio says there must be clear documentation as to what type of tissue one actually removed and cautions that simply stating “wound debrided” is not enough. Barbara Aung, DPM, CWS, also documents the wound size pre- and post-debridement. She also notes the tissues she removed and the instrument she used. Dr. Aung cites the importance of describing the wound’s surrounding tissue and exudate, along with any offloading and/or compression therapy that one uses. She says the last two items show the clinician is addressing the underlying medical condition that contributed to the development of the wound.

   When treating multiple ulcers, Dr. Poggio says one should remember that coding is per aggregate size of all similar (type of tissue debrided) ulcers after debridement regardless of where they are on the body. Therefore, he says billing each lesion with a right/left -51 modifier is no longer appropriate.

   Wound care specialists must have more than just a passing familiarity with the codes they commonly bill, according to Dr. Goldsmith. He says they should have a good understanding of coding definitions, guidelines and payer policies. Dr. Goldsmith suggests owning or having access to CPT, HCPCS and ICD-9-CM manuals. In addition, he says the American Podiatric Medical Association Coding Resource Center has those manuals online and Medicare contractor information is also online at . Dr. Goldsmith also suggests attending coding seminars and workshops hosted or presented by reputable organizations, companies and/or individuals.

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