Does dispensing surgical dressings at the same encounter as an ulcer debridement count as an evaluation and management (E/M)?
It depends on what was performed, documented, and medically necessary. You can submit an E/M at the same time as a debridement (or any procedure) if-and only if-an E/M was performed that was separately identifiable from the debridement.
That means if you separate out the components of the E/M that had no overlap with the debridement service, it should be able to stand as its own service separate from the debridement. This includes no overlap in the history, the exam, or the decision-making.
No “Automatic E/M”
Some are under the impression that making the decision to dispense surgical dressings, choosing the appropriate dressings, and explaining this all to the patient is an “automatic” separately identifiable E/M. That is not the case. Chances are there would be some overlap in at least one, and likely all three components of history, exam, and decision making between those performed for the debridement and those performed pertaining to dispensing surgical dressings.
When Can You Submit a Separate E/M?
An example of when it would be appropriate to submit a separately identifiable E/M along with debridement is when a patient has two ulcers. This would be appropriate if the documentation supported a debridement performed on one ulcer and a medically necessary, separately identifiable E/M performed on the other ulcer.
Another example would be a patient who had a second complaint that was unrelated to the debrided ulcer, such as a bunion, that required a separately indefinable E/M.
DISCLAIMER: The information provided here is intended to educate health care providers regarding compliance for diagnosis and CPT coding. The information provided does not guarantee reimbursement and is accurate to the best of our knowledge at the time of this publication. Coding guidelines can change and we encourage you to stay up to date. The existence of a code does not guarantee payment.
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.