decisionhealth Newsletters, decisionhealth - 2011 Issue 7 (July)
Wound Care / Separate EM
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Article Overview
This article addresses coding considerations for wound care visits where evaluation and management services may be reported in addition to debridement. It is aimed at coders and clinical documentation staff who need to understand when a separate service may be supported by the record, the role of medical necessity, and the general documentation themes involved in these encounters.
Why This Topic Matters
Wound care encounters are commonly repeated, and determining whether a separate evaluation and management service is supported affects compliant coding and documentation. The article helps readers recognize the broad circumstances and documentation focus involved in distinguishing routine follow-up care from a separately reportable service.
What You Will Learn
- How wound care encounters may be reviewed for separate evaluation and management reporting
- Why documentation and medical necessity are central to coding decisions in these visits
- What general kinds of clinical circumstances may prompt reassessment beyond routine debridement follow-up
- How repeat visits can differ from visits that involve additional workup or reassessment
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation specialists
- Wound care providers
- Revenue cycle staff
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