Here’s a fun little coding challenge for you. Get out your ICD-10-CM, CPT®, and HCPCS manuals, and see which codes you need to paint the full picture of this scenario.
One of your adult patients steps on a rusty nail, which opens up a 1.2 cm wound on the patient’s left foot. After two days, the patient comes into see your provider. After checking the wound and noting that the patient has not received a tetanus shot in over 10 years, the provider performs a simple closure of the wound.
The first problem confronting coders in this scenario involves whether to code for a separate evaluation and management (E/M) service.
If the patient is new to your practice, a separate E/M would be appropriate, as the provider would have no knowledge of other health issues prior to making the decision to do the surgery. Because of this, some payers may reimburse for a new-patient E/M from the 99201-99205 code range (Office or other outpatient visit for the evaluation and management of a new patient …). You’ll need to add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to indicate that the E/M service is separate and significant.
You can also make a similar case for coding a low-level E/M for an established patient. That’s because the provider will need to determine if the wound just needs to be cleaned and bandaged or needs sutures. Additionally, the provider needs to assess if the patient has been properly vaccinated against tetanus and if there is any infection in the foot as it has already been two days. So, providing the documentation in the medical record clearly supports that the provider did the work associated with an E/M service over and above the work associated with repair of the wound, you can report a low-level established patient E/M service such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient …), again with modifier 25 appended.
For the simple laceration, you would report 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less). If the patient is enrolled in Medicare, and the simple repair involved your provider using Dermabond, you can use HCPCS code G0168 (Wound closure utilizing tissue adhesive[s] only) instead. Per CPT®, you should code a wound closure using adhesive strips only with the appropriate E/M code rather than a wound repair code.
Coding caution: HCPCS code G0168 is considered a packaged supply code with the proper laceration repair codes and cannot be billed separately. This is because the CPT® codes for wound closure include using sutures, staples, or tissue adhesives, either singly or in combination with each other, or in combination with adhesive strips. So, there will not be a payment for the G code, but you should still bill it so that the payer knows it is a packaged supply.
As the patient is over the age of 7, the most likely choice of tetanus vaccination would be 90714 (Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use).
Here, again, your code choice will depend on your provider’s notes. Though the Td is the most likely choice, there are other tetanus-containing vaccines that the provider could use, too, but they would only be given if the patient had an indication or needed immunization against whooping cough, the flu, polio, or hepatitis B at the time of the injury.
Additionally, you would also use 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)) for the vaccine administration.
Here, too, you have many choices. Depending on the kind of wound your provider reports, you could code S91.332A (Puncture wound without foreign body, left foot, initial encounter) or S91.312A (Laceration without foreign body, left foot, initial encounter) from Chapter 19 of ICD-10. You may also have to code any wound infection should your provider’s notes indicate it, as the S91 codes come with Code Also instructions for you to do so.
Per that chapter’s Code Also note, you should use secondary, external cause codes from Chapter 20, such as W45.0XXA (Nail entering through skin, initial encounter) and/or Y93.01 (Activity, walking, marching and hiking).
External cause guideline note: In our recent post about external cause coding, we noted that “there is no national requirement for mandatory ICD‐10‐CM external cause code reporting” per ICD-10 guidelines. However, we also noted that reporting external causes is not only good coding practice, it may be necessary if states or payers mandate them.
Lastly, you would code Z23 (Encounter for immunization). This would not be listed as a primary diagnosis in this encounter, and it must be accompanied by procedure codes that identify “the actual administration of the injection and the types of immunizations given,” per ICD-10 guidelines.
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