Coding for repacking wound care and diabetic shock

July 24, 2018

Coding expert Bill Dacey explores coding for ongoing wound care and unexpected, extended care for a diabetic patient.

Q: Do you happen to know what the CPT code would be for when we change the packing in a wound after an incision and drainage (I&D) of an abscess? We do these quite a lot. I usually just bill a level 3, but we use a ton of supplies and it is a time-consuming visit. In addition, we are assessing for wound healing and infection.

A: There really isn't a CPT code for repacking and ongoing wound care. They have codes for wound care with debridement, negative vacuum pressure, etc. but nothing for repacking. And it's a common procedure.

I hope at least you are billing the complicated I&D to cover the initial packing. That 10061 instead of 10060 will get you something extra, but most folks bill the EM for this as you indicate. The EM would include the assessment for infection and coverage with antibiotics.

Be sure to also bill for the supplies, suture or surgical kits if you use them with the HCPCS codes as the supplies aren't bundled.

Q: I’m not sure how to code this. I have never had this happen before: A TCM visit, less than 7 days, for a demented diabetic patient admitted for bilateral pneumonia who now comes in with her daughter, a nurse. She came to the office really out of it, could sit unassisted but did not answer or open her eyes. Her vitals and O2 saturation were OK, but her glucose finger stick was 36. So now we are in urgent care/almost call 911 mode, getting orange juice and sugar, and repeating vitals. She gets more awake, we document that sugar is rising, then she is awake and opens her eyes, and can now answer questions at least yes or no. She is here about an hour. Can I code the TCM and a 99215, or extended visit?

A: That’s a tough one in part because you can't use the prolonged codes with a TCM code because the TCM code has no base time to get 'prolonged.' She is clearly at least high-level MDM, so the 7-day TCM is a good fit. A 99215 by time is 40 minutes, so you'd need a total of 70 minutes to get a 99215/99354 anyway.

You could bill critical care if this is a life-threatening event. Just state that you spent at least 30 minutes providing critical care, which is not place dependent. There is no CCI edit that says you can't bill a TCM with critical care.

Some providers report billing 99214 or 99215 with a TCM-and there is actually no edit that says you can't bill a 99215 or other EM either with 99496-but all the guidance on the TCM codes suggests that it was not intended to be billed with an AM on the same day.

It almost sounds like you didn't do much TCM but more of the needed urgent care. Did you do the required med reconciliation? Remember that the TCM needs to be the first E/M with the patient after the hospitalization. If you were to go with a 99215 instead of the TCM, you'd lose the TCM for that admit.

I'd take the 99496 TCM and be OK with that if you think you documented the TCM in terms of the hospital follow-up, Med reconciliation, and other required elements. The RVU is 3.05. A 99215 is 2.11. You're coming out OK, just not as good as a 99215/99354, which you are 10 minutes short for.

A critical care RVU is 4.5. What you did sounds somewhere between high MDM and critical care. It’s your call if you think it met that definition, e.g., was she at risk of a major organ system failure?