tci Part B Insider - 2010 Issue 6

YOUR PART B QUESTIONS ANSWERED: Remember to Represent Pressure Ulcer's Stage

Question: An established elderly patient reports to our physician for inspection of sores on her back. The doctor diagnoses a stage I pressure ulcer on her lower back and refers the patient to a dermatologist for treatment of the ulcer after a level-three E/M. How should I report this diagnosis? Answer: You should submit a pair of codes: one to represent the stage of the pressure ulcer and another for the ulcer itself. On the claim, report the following: • 99213 (Office or other outpatient visit for the evaluation and management of an established patient...) for the E/M...

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