tci E/M Coding Alert - 2016 Issue 8

Reader Question: Careful, That Open Wound Care Might Be an E/M

Question: What is the difference between an open and closed wound, and does open wound treatment automatically mean you can choose a procedure code? New Hampshire Subscriber Answer: An open wound occurs when the skin is cut, torn, or punctured. The most common types of open wounds are abrasion, avulsion, incision, laceration, and puncture. If you see any of these terms in the notes, and evidence that the skin was breached, your provider might have performed open wound treatment. Closed wound example: An established patient reports to the physician’s office with a badly bruised forearm. Another example could...

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