Medicare Compliance & Reimbursement - 2016 Issue 8
Reader Question: Careful, That Open Wound Care Might Be an E/M
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Article Overview
This article explains a common documentation distinction in wound care and discusses how the presence of an open wound, closure method, and related visit context affect the type of service discussed. It is aimed at coding professionals who review physician notes for wound treatment and office visit reporting. The article also touches on CPT and office/outpatient evaluation and management coding concepts in a general, non-exhaustive way.
Why This Topic Matters
Wound documentation can change how a service is interpreted for coding purposes, so coders and auditors need to recognize the terminology and service context used in the note.
What You Will Learn
- How open and closed wounds are described in clinical notes
- What kinds of closure methods are discussed in relation to wound care
- How wound-related documentation may relate to procedure reporting versus evaluation and management reporting
- Why documentation details matter when reviewing wound treatment notes
Who Should Read This
- Medical coders
- Coding auditors
- Physician practice staff
- Revenue cycle professionals
Codes Discussed
Code Ranges Discussed
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