Clinical Context
A 62-year-old patient with type 2 diabetes mellitus presents to a wound care clinic for evaluation of a chronic non-healing foot ulcer. The wound has purulent drainage and surrounding erythema. The clinician performs a focused history and physical, documents wound size, depth, and appearance, and obtains vital signs. To assist with targeted wound management and to evaluate bacterial burden and distribution before debridement or topical therapy, the clinician performs non-contact real-time fluorescence wound imaging (0372T). The imaging is completed in the outpatient wound care suite or ambulatory clinic room, captured using a handheld fluorescence device, and images are saved to the electronic medical record. Results indicating focal areas of elevated bacterial load guide wound bed preparation (for example, selective or non-selective debridement), sampling for culture when indicated, and selection of topical antimicrobials or dressings. The visit typically occurs in the outpatient clinic or wound center; documentation includes clinical indication (for example, E11.621, L97.909), time of imaging, findings, and how the imaging influenced wound management decisions. Billing is submitted for 0372T in addition to the evaluation/management or wound care procedure codes when supported by documentation and payer rules.