CODING & DOCUMENTATION

 


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Fam Pract Manag. 2016 Nov-Dec;23(6):31.

Author disclosure: no relevant financial affiliations disclosed.

Venipuncture at a follow-up visit

Q

What documentation is required when a medical assistant performs venipuncture on a date when the patient is not seen by the physician?

The documentation should refer to the written lab order by date and location (e.g., “in the 8/31/16 progress note”) and list the date of venipuncture, time, site, and patient tolerance of the procedure. All documentation should include the legible signature (written or electronic) and credentials of the individual performing the service.

Debridement of subcutaneous tissue

Q

Which CPT code should be reported for debridement of subcutaneous tissue on two separate wounds?

Code 11042, “Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 cm2 or less,” is reported once for the first 20 square centimeters or less of the combined wound surface measurements. When multiple wounds are debrided at the same level, use the sum of their surface areas in code selection. However, if multiple wounds are debrided at different levels, report separate codes for each wound (e.g., 11042 for debridement of subcutaneous tissue and 11043 for debridement of muscle and/or

About the Author

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Cindy Hughes is an independent consulting editor....

Author disclosure: no relevant financial affiliations disclosed.

These answers were reviewed by members of the FPM Coding & Documentation Review Panel, including Kenneth Beckman, MD, MBA, CPE; Robert H. Bösl, MD, FAAFP; Marie Felger, CPC, CCS-P; Thomas A. Felger, MD, DABFP, CMCM; Emily Hill, PA-C; Joy Newby, LPN, CPC; and Susan Welsh, CPC, MHA.

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Send questions and comments to fpmedit@aafp.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.


 

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