Billing For an E/M

“I am not sure when I should and can bill for an E/M when seeing patients for wound care. Is it reasonable to bill an E/M code if the patient returns for follow up for their ulcer and it is 100% healed? Occasionally hyperkeratotic tissue is present and sometimes I debride the callus to confirm the ulcer has healed. I always spend time on these visits educating the patient on ulcers and the diabetic foot. Would it be appropriate to code for an E/M at this visit since the vast majority of the time is spent counseling the patient prior to discharging them from care?”

Based upon the medical record documentation, in most instances when a patient is being seen at a follow up visit for the status of an ulcer, it can be appropriate to bill for an E/M service based upon the status of the ulcer if debridement is not needed and performed. With respect to the patient having an ulcer on the foot and is being evaluated on the date of the encounter to establish whether the ulcer has healed, billing for an E/M service can certainly be justifiable.

As I have opined in the past, an E/M service is defined as the following:

1. 1. E/M is NOT a synonym for an office visit.
2. 2. It is a 2 part process:
3. a. “E” stands for EVALUATION. Using a Medically Appropriate History and/or Examination and *Medical Decision Making, you formulate a WORKING DIAGNOSIS. This shows MEDICAL NECESSITY.
4. b. “M” stands for management. Using the working diagnosis, you now have to do something about it. In other words, you have to TREAT THE PROBLEM. Diagnosing a problem is not sufficient.
5. 3. *Total Time can be used in lieu of Medical Decision Making in order to determine the most appropriate level of E/M service as long as the total time is appropriately documented within the medical record for the date of service in question.

In the above post, the patient had a history of an ulcer. When the overlying hyperkeratosis at the site of the ulcer was debrided, the ulcer appeared to be resolved. Even though time is spent educating the patient on ulcers and the diabetic foot, I don’t feel that it would be appropriate to base the E/M visit on “total time” for two reasons. First of all, I am sure that this would not be the first time that this discussion was held with this patient since he/she is diabetic and the ulcer has been treated previously for a designated period of time. Secondly, billing an E/M service based on total time more often then not tends to raise the level of E/M service greater than if medical decision making was used.

Since the ulcerative lesion is resolved, it would be important to educate the patient on what needs to be performed on his/her part to prevent the ulcer from reoccurring and what the patient needs to do if the ulcer does return. An example might be the following:
“The patient was instructed to wear an appropriate sneaker or shoe on the affected foot whenever walking or performing outside activities. The patient was instructed to never go barefoot inside and outside of the house. The patient is to inspect his/her feet on a daily basis, especially the site of the previous ulcer. If the ulcer reoccurs or a new sore develops, the patient was instructed to contact the office ASAP for an appointment. All questions by the patient were addressed, discussed, and answered.”

This documentation plus the medically appropriate history and the medically appropriate examination in the medical record for this date of service plus medical decision making of low complexity would support the billing of E/M code CPT 99213. Medical decision making would be of low complexity based upon the fact that the patient is an “at risk” patient with a history of diabetes mellitus and an ulcer on the plantar aspect of the foot with the distinct possibility of the same ulcer reoccurring or a new ulcer developing.

This is my opinion.

Michael G. Warshaw

DPM, CPC

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