Pertinent Insights On Coding For Wound Care

Author(s): 
Clinical Editor: Kazu Suzuki, DPM, CWS

Q:

Do you have any tips on coding for evaluation and management (E&M) in common podiatry practice?

A:

Generally, Dr. Aung suggests documenting using either paper history and physical exam forms, or an electronic health record (EHR) configured to collect the data required to document the services performed. One should avoid using EHR templates that just copy the same information from visit to visit. Dr. Aung says rote EHR template notes invite targeting by auditors and “would not support the level of services actually performed or provide justification to meet medical necessity.”

   Prior to the introduction of E&M coding over 20 years ago, Dr. Goldsmith notes there were no hard and fast guidelines as to what qualified the level of outpatient or inpatient “visit” coding. Evaluation and management service coding changed all that. He offers the following tips for E&M billing.

• The volume (pertinent versus “fluff”) of medical record documentation presented may have nothing to do with the ultimate level of E&M service warranted.
• Not all patient encounters qualify as reimbursable E&M services.
• Each patient encounter is unique in terms of E&M qualification or level of service.
• One determines E&M service levels not only by the documentation but by medically relevant circumstances, comorbidities, age, activity, medical necessity and standard of care.
• When performing minor procedures, one must clearly document E&M as “significant, separately identifiable” from the inherent E&M within the procedure coding allowance.
• Know your E&M service modifiers. Access the National Correct Coding Initiative edits to determine whether the E&M and procedure are bundled, and if one can have them unbundled.
• For established patients returning for follow-up of a specific condition, only interval changes to history, examination and/or medical decision making define the level (if any) of E&M service billable.

Q:

What are the examples of office modifiers for E&M codes, such as -24 (unrelated E&M services) or -57 (decision for surgery), in podiatry practice?

A:

As Dr. Suzuki explains, modifier -24 allows physicians to perform office services for unrelated diagnoses during the post-op global period. Dr. Aung says an example of this would be reporting an ingrown toenail (either on the same foot as surgery or the contralateral limb) for a patient who presents for a post-op visit five days after a bunionectomy.

   Modifier -57 (decision for surgery) may be more important and more frequently used in wound care practice, according to Dr. Suzuki. He explains that usually physicians are not allowed to charge for E&M for the same day of procedure as it falls on the global period, unless one adds this “decision for surgery” modifier to indicate that one spent extra time of E&M to work up the patient. Dr. Poggio adds that the -57 modifier covers a 90-day global period.

   Dr. Goldsmith poses a hypothetical example. A doctor is called to the emergency department of his hospital to consult on a patient who had a contusion and laceration of her right foot when she accidentally kicked the shower door. The examination of the foot reveals some simple and intermediate lacerations, and an open, displaced fracture of the distal fifth metatarsal. The surgeon scheduled the patient for surgical repair first thing in the morning. In order to avoid only being paid for the fracture and laceration repair, Dr. Goldsmith says one would append a -57 modifier to the outpatient E&M service code. He cautions that the use of the -57 modifier implies that the major surgical procedure(s) will occur within 24 hours of the decision for surgery.

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