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Code This!

Scenario Week of July 27, 2012:
View Current Scenario

HISTORY:
Chief complaint
: This is a male patient who is 86 years of age. He presents as a new patient today for complaints of right lateral ulcer, nail, and foot care.
History of present illness:
Location: Ulcer right foot, nail and foot care bilateral feet
Quality: The patient is uncomfortable
Severity: Moderate
Timing: Pain comes and goes in intensity
Health history: Patient completed medical history form. Of note, the patient has a long history of psoriasis. Takes medications for hypertension and hypercholesterolemia. No history of heart attack or other chronic conditions.

Review of systems:
Constitutional: Negative
Eyes: Negative
Cardiovascular: Palpitations, hypertension
Gastrointestinal: Negative
Musculoskeletal: Joint stiffness, muscle weakness, not diagnosed as arthritis
Skin: Color changes, dry skin, rashes, psoriasis
Neurological: Negative
Endocrine: Negative

Exam:
Vital signs: Temperature 98.0, pulse 107, respirations 20, blood pressure 147/88, height 5 ft. 8 in., weight: 206 lbs
Skin: No hyperkeratoses observed. Dermatophytosis noted. Plaque-like lesions on both legs and back. Mycotic nails, both feet. Foot ulcer right foot. Edema of both lower extremities and feet.
Cardiovascular: Peripheral vascular disease
Musculoskeletal: Difficulty walking. Pain in lower extremities and feet.

Assessment:
Ulcer, right foot
Onychomycosis nails
Peripheral vascular disease
Psoriasis

Procedure:
Ulcer of the plantar area of the right lateral foot. A 3 x 3 area of the ulcer bed was debrided, including removal of epidermal and dermal tissues to demarcated margins. Pink wound bed. No active bleeding present. Treated with gentian violet. Dressing applied. Patient instructed in wound care and advised to wear shoes.

Sharp debridement of nine mycotic nails.

Plan:
Patient to change dressing daily. Instructed to wear shoes and inserts and to return to the clinic in nine weeks for at risk foot care. Patient instructed to return soon for any new concerns or if the ulcer does not heal within two to three weeks.

The start of the ulcer could have been from his severe condition of psoriasis. He has multiple plaque-like lesions on both legs and back. A lesion on his foot is believed to have started the ulcer. The patient is referred to a dermatologist for treatment of the psoriasis.

Code this! Assign the appropriate ICD-9-CM diagnosis codes and the appropriate CPT code(s).


ICD-9-CM answer:
707.15 Ulcer of other part of foot
110.1 Dermatophytosis of nail
443.9 Unspecified peripheral vascular disease
696.1 Other psoriasis

Rationale:
As the first-listed procedure, the ulcer of the foot is reported with 707.15. The documentation does not specify the type of ulcer and so the other code options for a foot ulcer are not appropriate. The dermatophytosis of the nail is reported with 110.1 for all nails. This code is more specific than the code for dermatophytosis of the foot. The provider has not further identified the peripheral vascular disease and so code 443.9 is the most appropriate designation. The provider has identified the skin disease of psoriasis (696.1), with no other specification provided.

CPT answer:
99203-25 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

11721-59 Debridement of nail(s) by any method(s); 6 or more Distinct procedural service

Rationale:
The provider is using a template that identifies the specific element of an evaluation and management (E/M) service. Note that this template allowed for the provider to note patient-specific information and the provider documented more than “normal” or “negative” for most of the template prompts. The history is detailed with chief compliant, four elements of history of present illness, review of more than two systems, and at least one element of past, family and social history. The exam involves more than two systems but fewer than eight. The level of detail involving the skin is greater than would be expected in an expanded exam. The medical decision making notes that the foot ulcer and mycotic nails are new problems to the examiner. No data were reviewed. The debridement is minor surgery with no identified risk factors for low risk. This is a total level of low complexity decision making. This meets the definition of code 99203.

Since the E/M service was performed to evaluate the patient and the new problems, it may be reported. However, modifier 25 should be appended to indicate that the E/M service was separate from the procedures also performed on the same date.

The ulcer debridement was an area of 3 x 3, or 9 sq cm, of epidermal and dermal tissue. This meets the definition of debridement of the dermis and epidermis as found in code 97597. The surgical debridement codes (11042–11044) would be inappropriate as the debridement did not extend at least into the fascia. Reporting the excision of a pressure ulcer (15920–15999) would also be inappropriate as this was debridement, not excision, and the pressure ulcers are reported by site and do not include the plantar surface of the foot.

Mycotic nails were debrided. It is appropriate to report code 11721 as six or more nails were treated. If five or less were treated, code 11720 would be reported.

Codes 11721 and 97597 are subject to a mutually exclusive CCI edit, but a modifier is allowed to override this edit in this instance. It is appropriate to report both procedures because the debridement is on the plantar surface of the foot, separate from the nail debridement.

 
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