How To Get Optimal Reimbursement For Wound Debridement And Skin Substitutes

Clinical Editor: Kazu Suzuki, DPM, CWS

These knowledgeable panelists provide insights on using appropriate codes for wound debridement and skin substitutes to maximize reimbursement. They also address the correct use of modifiers and offer coding pearls for those entering practice.


What is the right way to bill for wound debridement in the office and in the OR?


For wound debridement, Anthony Poggio, DPM, suggests describing the wound, appearance, odor, wound base and surrounding inflammation/infection as well as the size of the wound both pre- and post-debridement. He says one should be very specific and document the tissue actually debrided. Dr. Poggio adds that the fact that the wound goes to muscle does not automatically imply that one debrided muscle. He says podiatrists should add up the aggregate size of all similar wounds (based upon the type of tissue debrided).

   Similarly, Kazu Suzuki, DPM, adds that last year, CPT codes changed to reflect the wound surface area that one debrided in 20 cm2 increments.

   “The rule of thumb is the debridement depth level is based on what you remove and not what you see,” he says. While one may often see bone or tendon in a wound, Dr. Suzuki says podiatrists should code for 11042 (subcutaneous level debridement) if they are only removing subcutaneous tissues.

   Barbara Aung, DPM, encourages podiatrists to know the appropriate codes for the appropriate level of debridement and how to calculate wound area for the appropriate skin substitute code.

   “With the current focus on wound care and post-payment reviews, proper documentation is of utmost importance,” notes Dr. Aung. “Being able to meet medical necessity so the documentation supports what is billed is the key to keeping the reimbursement you have earned for the services you have performed.”

   In addition, Dr. Poggio suggests documenting the use of anesthesia if applicable and documenting the type of instrumentation one utilized.


How do you code for skin substitute applications?


As Dr. Suzuki notes, CPT codes for skin substitutes changed drastically in 2012. He explains that the new series of skin substitute codes is based on the anatomic location as opposed to which products (i.e. Dermagraft, Graftjacket) are in use while DPMs still receive reimbursement for the product based on the Q code. Dr. Suzuki says those codes are now uniform with skin graft codes, and are anatomically separated in two areas, CPT 15271 for the body (trunk, arms, legs) and CPT 15275 for extremities (hands, feet including heels). Similar to wound debridement, the skin substitute codes are coded based on increments of 25 cm2, according to Dr. Suzuki.

   Dr. Aung says one should bill all “skin substitute” applications using the same set of codes regardless of the product. She says one should select the code based on the total area of the ulcer/wound and the site of skin substitute application. Dr. Aung adds that one may separately report the supply of the actual product (the skin substitute graft itself) using a HCPCS II supply code by the provider that incurred the expense. Dr. Poggio adds that one may bill for both the graft material and the application of that material.

   For example, Dr. Aung says one should report the application of a 25 cm2 allograft to a foot with code 15275. Report each subsequent 25 cm2 allograft up to 100 cm2 with the add-on code +15276. Therefore, one would report a 42 cm2 allograft application to a foot with two codes: 15275 and +15276, according to Dr. Aung.

   However, she notes that if the total surface area of allograft application is 100 cm2 or greater, this requires different codes for the first 100 cm2. For example, Dr. Aung advises reporting the application of 170 cm2 of allograft to both feet with two codes: 15277 and +15278.


What are useful modifiers for wound care practice?


Modifier -58 is for a staged or related procedure, such as a serial OR debridement when one knows that more than one surgical setting is required, according to Dr. Aung.

   Modifier -58 is probably the most used modifier in the wound care setting, asserts Dr. Suzuki, who notes that DPMs often must “stage” a wound closure for complex wounds. Citing the example of a grossly infected foot wound, he notes he may have to perform a partial foot amputation, use VAC therapy (KCI) and subsequently take the patient back to the OR for a definitive wound closure. Since a foot amputation carries a global period of 90 days, Dr. Suzuki says one would need to use -58 to allow for reimbursement of the second procedure (wound closure).

   Dr. Suzuki says one would use modifier -78 (return to the OR) for treatment of a complication or an unplanned surgical procedure. He cites the example of an evacuation of a hematoma after an elective procedure such as a bunionectomy. For modifier -78, Dr. Aung cites the example of a deep incision and drainage/debridement for a partial foot amputation followed a few days later by a second surgery after one discovers infection of the amputation site.

   Modifier -79 (an unrelated procedure in the post-op period) protects the second procedure from receiving less payment, notes Dr. Suzuki. For example, Dr. Aung says one may perform a deep I&D/debridement on the right foot and on the follow-up visit, the patient develops an ulcer on the left foot that needs debridement.

   When using this modifier, Dr. Suzuki says one should indicate that the post-op period of the first procedure was unrelated to the second procedure. He rarely uses this code, preferring to let the patient heal completely before doing any other elective surgical procedure.


Do you have any advice regarding coding and billing to the current residents who will be in practice in a few years?


“If you haven’t learned how to code, start now,” advises Dr. Suzuki. “I believe learning how to code your procedures appropriately is the best way to maximize your income, unless you know that you are going to be a lifetime salaried physician, which is very unlikely.”

   Dr. Aung agrees. She advises residents to learn how to use the CPT and ICD 9 or ICD 10 codes as well as the HCPCS codes when it comes time for practice.

   “Whether you work for a hospital organization, a specialty group and/or enter private practice, you are ultimately responsible for what gets billed out for services you have performed,” says Dr. Aung.

   Dr. Aung suggests starting a study group with fellow residents of any specialty to learn about billing and coding or having the residency program add billing and coding as part of a journal club or online learning through PRESENT Podiatry. Although it is not necessary to memorize the codes, she says one should know how to look up the codes and/or how to talk to coders and billers when they have queries before they bill out for your services.

   Dr. Suzuki cautions that there is a plenty of “gamesmanship” one must learn involving surgical coding. When physicians perform a complex procedure, there may be three different ways to code the procedure and the reimbursement will be drastically different, according to Dr. Suzuki.

   For example, he says for a diabetic foot ulcer with osteomyelitis, one can debride the wound and the bone, then fashion the skin flap and close the wound. In this case, Dr. Suzuki notes one could code it as a bone debridement, an ostectomy or a complex wound closure. Those procedures may be exclusive to each other (one cannot bill them together) and he says they get reimbursements at different amounts.

   Dr. Poggio suggests reviewing the indications for each graft material as some grafts are only allowed for patients with diabetes even though a person without diabetes has a similar wound and/or risk factors. He says one should also get pre-authorization for every graft just to make sure the graft has coverage, noting that many suppliers will do an insurance verification for you.

   Dr. Poggio emphasizes that graft material can cost hundreds or thousands of dollars. If the insurance carrier does not pay, the physician is still responsible for the cost of the graft material, points out Dr. Poggio.

   “Even though I have worked with surgeons that let the office billers ‘code’ for them based on the dictated op reports, I believe it is the best policy for the surgeon to code his or her procedures since you know exactly what was performed in the particular situation,” says Dr. Suzuki.

   Dr. Aung is in private practice in Tucson, Ariz. She is a member of the American Academy of Professional Coders as a Certified Professional Medical Auditor. She is also a panel doctor at Carondelet St. Mary’s Advanced Wound & Hyperbaric Center in Tucson. Dr. Aung serves on the Examination Committees for both the American Board of Wound Management and the American Board of Podiatric Orthopedics and Primary Podiatric Medicine.

   Dr. Poggio is a California Podiatric Medicine Association Liaison to Palmetto GBA J1 MAC and 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 and Primary Podiatric Medicine.

   Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo.

   Editor’s note: For further reading, see “Pertinent Insights On Coding For Wound Care” in the July 2012 issue of Podiatry Today or “What You Should Know About Skin Grafts And Substitutes” in the January 2011 issue.

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