A Guide To Coding For Outpatient And In-Hospital Debridement

Start Page: 66

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.

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Author(s): 
Anthony Poggio, DPM

   These wounds can be anywhere on the body. There are no bilateral T or F modifiers required. Furthermore, if you only bill these two codes together, there is no need to append any modifiers such as a 59 modifier to CPT 97598 when billing with CPT 97597. When it comes to both CPT 97597 and CPT 97598, you should bill these at their full allowed value. There is already a fee adjustment included in the allowance for CPT 97598. However, additional modifiers may be required if you are billing other services (procedures or E/M services) along with CPT 97597/97598 for the same visit.

   Note: Do not bill CPT 97597 and 97598 with CPT 11042-11047 as the latter codes include the skin debridement.

   Note: Do not use CPT 97597 and 97598 codes in a skilled nursing facility setting as they are part of skilled nursing facility consolidated billing protocols. Therefore, you should discuss this with nursing facilities for direct payment from them for these services.

   Note: Unna boot application will be allowed in addition to CPT 97597 and CPT 97598 by appending the dressing code CPT 29580/29581 with a 59 modifier.

Other Pertinent CPT Coding Changes

CPT codes 11040 and 11041. As I noted earlier, these codes have been deleted for all uses.

   CPT 11042. This code continues to address the debridement of wounds down to and including subcutaneous tissue. However, the descriptor has changed to debridement of subcutaneous tissue (which includes epidermis and dermis) for the first 20 cm² or less. Again, as with CPT codes 97597 and 97598, this code is for aggregate size of similar wounds (based upon the type of tissue debrided) for the first 20 cm² or less, not per wound.

   CPT 11045. This is a new code that was squeezed in between CPT 11042 and 11043 (it is out of sequence). This code is also for debridement of subcutaneous tissue (including epidermis and dermis) but clinicians can use this code for each additional 20 cm² increments or part thereof. One can bill this code in multiple increments. Again, do not use any modifiers when billing this code in conjunction with 11042 unless other procedures dictate the use of a modifier.

   CPT 11043. This has been changed to debridement of muscle and/or fascia (includes epidermis, dermis and subcutaneous tissue, if performed). This applies to the first 20 cm2 or less.

   CPT 11046. This is a new code that was squeezed in between 11043 and 11044 (it is out of sequence). Its description is debridement, muscle and/or fascia (includes epidermis, dermis and subcutaneous tissue) for each additional 20 cm² or part thereof. Bill this code in conjunction with CPT 11043.

   CPT 11044. This has been changed to debridement of bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed). It applies to the first 20 cm² or less.

   CPT 11047. This is a new code for debridement of bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia) for each additional 20 cm² or part thereof. Bill this code in conjunction with CPT 11044.

How To Select The Correct Debridement Codes

In summary, select the CPT codes 97597/97598 and 11042-11047 based upon the following three criteria.

   1) The type of tissue debrided, not necessarily the depth of the wound. If you only debride subcutaneous tissue on a wound that has bone exposed, you would still only bill CPT 11042 as subcutaneous tissue is what you debrided from the wound.

   2) The aggregate size of the wounds based upon 20 cm² increments, not the number of individual wounds.

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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:

CPT RVUs
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

Reply to this comment »
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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