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Sample note

Diabetic foot ulcer · f/u

Subjective: 67-year-old established male, T2DM x 12 yrs, f/u of chronic non-healing ulcer right plantar heel, 8 weeks. Adherent to offloading boot.

Plan: Sharp debridement: 4 sq cm of devitalized subcutaneous tissue from right plantar heel using #15 blade. Cleansed, collagen dressing, offloading boot continued.

Total face-to-face time: 25 minutes.

Drafted Claim · 2 lines

$291.40 · 2.90 wRVU · NORTHERN NJ

trace_id lf_t_dev_a3f82b42

Warning · 99214 is drafted alongside a same-day procedure but does not carry modifier 25. CMS will deny the E/M without it.
99214High · 90%
$145.90

Established patient office visit, moderate complexity

"67-year-old established male, T2DM x 12 yrs..."

Supports dx3
  • 1E11.621T2DM with foot ulcer
  • 2L97.411Non-prs chr ulcer of right heel
  • 3B35.1Tinea unguium
WEAK · NCCI vs 11042 (mi=1)
MDM · Problems mod · Data mod · Risk mod
11042High · 95%
$145.50

Wound debridement into subcutaneous tissue

"Sharp debridement performed: 4 sq cm of devitalized subcutaneous tissue from right plantar heel..."

Supports dx2
  • 1E11.621T2DM with foot ulcer
  • 2L97.411Non-prs chr ulcer of right heel
WEAK · NCCI vs 99214
Global 000 · 5 coverage rules (LCD A55909, A56617, A58565, A56459, A56175)

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