Is it appropriate to submit an evaluation and management (E&M) service when a patient presents with a healed ulcer? It depends. Probably, but it depends on what was performed and documented.
An E&M occurs when a presenting problem is evaluated by way of history and exam and the provider uses their education and expertise to medically manage the condition. Some examples of the management component of an E&M include writing a prescription, making a recommendation, suggesting an over-the-counter product, and referring a patient to another provider.
Determining The Ulcer Is Healed
In most cases, a patient cannot be certain that an ulcer is healed until a trained professional determines it is healed by way of history and physical exam. Furthermore, in most cases that a patient presents with a healed ulcer, the provider makes recommendations regarding how to care for the area and try to prevent recurrence.
In the eyes of most auditors, a progress note that merely reads, “Ulcer is healed – discontinue topical care” will not substantiate the submission of an E&M service. On the other hand, a progress note that includes a history and exam pertinent to the healed ulcer and documentation of recommendations that were made should support the submission of an E&M service. This history may include the patient’s report of not seeing any more drainage, not detecting any odor or discoloration to the site, having no pain, not seeing any blood on their sock or bandages, and being unable to see any opening in the skin themselves. This exam may include the provider’s observation that the area is fully epithelized with no discoloration, defects, heat, fluctuance, maceration, or odor. Finally, the documented management component of this encounter could include the provider’s explanation to the patient that the ulcer is healed, what changes to make regarding local care to the area, what can be done to try to prevent recurrence, and concerning things to watch for that would necessitate a return to the provider for another evaluation.
An E&M service may be submitted when seeing a patient with a healed ulcer if the elements of an E&M described above are medically necessary, performed, and documented.
Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Dr. Lehrman is a podiatrist practicing in Fort Collins, CO and operates Lehrman Consulting, LLC which provides consultation services regarding coding, compliance and documentation. Dr. Lehrman is a Certified Professional Coder and Certified Professional Medical Auditor. He serves as a staff liaison at the AMA CPT® Editorial Panel meetings where CPT codes are created, edited, and deleted. He is a Diplomate of the American Board of Foot and Ankle Surgery, Fellow of the American Society of Podiatric Surgeons, and is recognized as a “Master” by the American Professional Wound Care Association. Dr Lehrman is a Fellow of the American Academy of Podiatric Practice Management, Past Director of the American Professional Wound Care Association Board of Directors, and is a Past Chairman of the Board of the American Society of Podiatric Surgeons. Dr. Lehrman is also on the editorial advisory board of the journal WOUNDS.