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.

69
Author(s): 
Anthony Poggio, DPM

   3) If there are multiple wounds from which you have debrided a different tissue type, lump all similar wounds (based on the type of tissue you have debrided) together.
For example, if debriding bone from wound #1 (< 20 cm²), bill CPT 11044. If debriding muscle from wound #2 (<20 cm²), then also bill CPT 11043 -59 for the second wound since you are debriding different tissue. Append the lesser debridement code with the 59 modifier.

   On the other hand, if the above scenario includes debridement of bone from wound #1 (<20 cm²) and debridement of muscle from multiple wounds with an aggregate of 30 cm², billing would be CPT 11044 for wound #1 (<20 cm²) and CPT 11043-59 (for the first 20 cm²) along with CPT 11046 for the additional >20 cm2 debrided for the other combined similar wounds.

   You can mix and match all combinations of CPT code 11042-11047 based upon the tissue you have debrided and the aggregate size of the wounds. Use 59 modifiers to separate out each principal debridement code (versus add-on codes).

   The global period for all debridement codes is now “zero” days. Keep in mind that the wound debridement codes may still be impacted from the global period of other procedures (such as amputation or other surgery) you may have performed.

Ensure Proper Coding For Wound Preparation For Grafting And NPWT

Preparing a wound for application of skin grafts, skin substitutes or skin flaps may require tissue debridement. Applying a negative pressure wound therapy (NPWT) device may also require tissue debridement. The goal is that wounds treated with these modalities will heal by primary intention or NPWT. Use CPT codes 15002-15005 for tissue debridement for this. These codes are listed in 100 cm² increments.

   Do not use these codes for wounds in which the intent is that they will heal by secondary intention. For these wounds, use the active wound care codes, which are CPT 97597-97598 and 11042-11047.

   Do not use CPT codes 15002-15005 in conjunction with the application of tissue cultured allogenic skin substitutes.

   Clinicians commonly use vacuum assisted closure (VAC) devices as adjunctive therapy after wound debridement. The two codes for the application of the VAC device are: CPT 97605 for a wound diameter of less than or equal to 50 cm² and CPT 97606 for wounds greater than 50 cm². CPT 97606 is not an add-on code so do not bill these two codes together. Only bill one or the other.

   When billing these codes, you must list your national provider identifier (NPI) number in box 17 in order to receive payment.

   Dr. Poggio is a California Podiatric Medicine Association Liaison to Palmetto GBA Medicare J1 MAC and is a medical consultant to several national health insurance and review organizations. He is a member of the American College of Podiatric Medical Reviewers and is board certified by the American Board of Podiatric Medicine and the American Board of Podiatric Orthopedics.

   For further reading, see “Key Pearls On Coding For Bunionectomies” in the February 2010 issue of Podiatry Today or “Key Coding Insights For Skin And Wound Conditions” in the October 2004 issue.

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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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