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Recording and Coding Wounds Properly

Recording and Coding Wounds Properly

Any person who is involved in the medical field already knows just how important it can be when it comes to putting down the proper codes for each and every procedure. Taking care and making sure that the right code is recorded for the proper procedure can ensure that there will not be any problem down the line with health care providers and insurance carriers. However, sometimes it may be a bit more difficult to decide exactly which code needs to be used in every instance. Take the time to find out what the medical code should be before you end up reporting the wrong one and this could alleviate problems before they even happen.

For example, if you are working on a patient who comes in with a wound and they are covered under Medicare, they would need a different code than a patient who does not, depending on the exact type of procedure that is performed. The way to distinguish the difference would be to take note of whether or not sutures were used or if the wound was able to be closed up with some type of tissue adhesive such as Dermabond. Such a closing with tissue adhesive for a Medicare patient would have to be recorded using the code G0168, which is for a wound closure using only tissue adhesive.

When trying to stay on top of properly recording all wound codes, you really need to be sure that the claims document always includes the length of the repair that needs to take place. Usually, a physician will need to record the entire length as well as the location within the notes for a complete report.

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