A Guide To Coding For Outpatient And In-Hospital Debridement

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A Primer On Effective Chart Documentation

In the history portion of your chart note, continue to list the onset of the ulcers, possible precipitating factors/trauma, previous treatments rendered, etc. Also include in your charting comorbidities, such as peripheral vascular disease, neuropathy, metabolic conditions and immunocompromised states, that may impact healing.

In your chart, there should be documentation of the measures you took to address any risk factors. Indicate additional diagnostic testing done/anticipated (such as bone scan/magnetic resonance imaging for possible osteomyelitis). Note other specialist consultations (such as vascular evaluation for a non-healing ulcer, infectious disease consult for antibiotic therapy modifications, etc). Document offloading measures, patient/family discussion regarding adherence, etc.

In the examination portion of your chart note, you should list the location of each ulcer(s), size of the ulcer(s), description of the ulcer base, drainage, odor, surrounding cellulitis, etc. Hopefully as the wounds improve, your chart note will reflect these changes or document any deterioration of the condition.

In the treatment portion of your chart note, be sure to note what specific type of tissue you debrided. Clearly document whether you debrided skin versus subcutaneous tissue versus muscle versus bone from a wound(s) to qualify for the use of that debridement code. As the ulcer improves, the type of tissue and therefore choice of debridement codes should reflect this as well.

As always, be careful in the use of templates when you document. Simply “cutting and pasting” portions of the previous chart note without documentation of findings/changes specific to that date of service may result in a poor quality chart note. Accordingly, the information listed may not validate your findings and treatment decision for that day. This applies to both a billing perspective as well as a medical-legal perspective.

Anthony Poggio, DPM

In order to ensure proper coding and timely reimbursement, it is essential to have a heightened awareness of recent changes to debridement codes. Accordingly, this author offers a closer look at the new codes and discusses criteria for selecting the proper codes.

Wound care has become a more prominent subspecialty in medicine. The number of wound care products, adjunct treatment modalities and treatment algorithms is constantly changing. Podiatrists are performing a significant amount of wound care. Proper coding of these treatment modalities is therefore very important.

   As of Jan. 1, 2011, there have been several coding changes that affect wound care billing. The CPT codes 11040 and 11041 have been deleted. This CPT code deletion impacts all insurance carriers that follow CPT coding guidelines.

   The proper selection of the remaining and the new CPT wound care/debridement codes is now based upon the type of tissue debrided, not just the depth of the wound (no real change there).

   In addition, as of Jan. 1, 2011, one must document the size of the wound(s) listed by dimension and/or in square centimeter size, and select billing codes based upon total aggregate size of similar wounds (based upon type of tissue debrided) regardless of where they are on the body. This billing protocol is consistent for all of the wound care debridement CPT codes valid as of Jan. 1, 2011.

Key Changes To Debridement CPT Codes

The CPT code series CPT 11010 -11012 description has changed to:

   CPT 11010. This indicates debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e.g., excisional debridement) as well as in skin and subcutaneous tissues.

   CPT 11011. This indicates debridement including removal of foreign material in skin, subcutaneous tissue, muscle fascia and muscle.

   CPT 11012. This indicates debridement including removal of foreign material in skin, subcutaneous tissue, muscle fascia, muscle and bone.

   CPT 97597-97598. This code series has had one of the more significant changes. Previously, these codes were to be used by non-physicians but now these codes are to be used by all providers who perform this service.

   The code description includes debridement (utilizing various means including sharp debridement) of devitalized epidermis or dermis, fibrin, exudate, debris, biofilm, etc. from open wounds. Again, the type of material/tissue documented as being debrided in the chart is key here. One could use this code series for debridement of the superficial fibrin, exudates, etc., from any wound including the base of deeper wounds when no specific deep tissue (subcutaneous, muscle, bone) is documented as being debrided.

Current Insights On Billing Wounds Per Aggregate Size

The other major change in wound care coding this year is that one cannot bill wounds per lesion. Rather, physicians should bill per aggregate size of all wounds in which they are debriding similar tissue.

   One would use CPT 97597 to bill for debridement of the first 20 cm² of aggregate wound size. Use CPT 97598 for any subsequent 20 cm² increments of debrided tissue. For example, if there are two wounds that have partial- or full-thickness debridement as described by CPT 97597, and one wound is 5 cm² and the other is 10 cm², the coding would be CPT 97597. Bill this once because CPT 97597 allows for up to 20 cm².

   On the other hand, if the first wound measured 10 cm² and the second wound measured 15 cm², then the aggregate of the two wounds would be 25 cm². The coding would then be CPT 97597 for the first 20 cm² and CPT 97598 for the remaining 5 cm². If the aggregate wound size for the two wounds is 50 cm², then proper billing will be CPT code 97597 for the first 20 cm² and CPT code 97598 — unit two in box 24G on the CMS 1500 form or ECS equivalent — for the remaining 30 cm² (20 cm² plus 10 cm²). One would bill CPT 97598 in 20 cm² increments or portion thereof.

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Drsilversays: August 11, 2011 at 9:31 am

When I first heard that CPT 11040 & 11041 were being deleted for wound debridement, I was upset. I thought that I would receive less reimbursement for wound care as they were changing the codes to previously "non-physician" codes.

I was mistaken. I have found that 97597 pays more than 11040 and 11041 did previously.

Compare the Total RVU's and see why:

11040 1.40
11041 1.64
97597 2.22
11042 2.55

Once in a while, these changes actually help us providers. One for the good guys this time!

Hope this helps!

Lawrence Silverberg, DPM
blog: www.bestpodiatristnyc.com

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KDTsays: September 23, 2011 at 1:55 pm

I work with a hospital wound care clinic and I am confused by the statement above (also in CPT Asst May 2011) about billing 29581 with 97597/97598. Both say it is okay to bill this way so why is there a NCCI edit in place if this is so clear cut? What is it about that scenario that makes it okay to modify with 59? It is same anatomic site?

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