Coding And Wound Care: What You Should Know

As ICD-10 requirements take effect, this author discusses accurate coding in wound care, particularly for dressing changes and debridement, so your facility can get optimal reimbursement for services.

The topic of wound care coding has been the subject of coverage in many publications and by many “experts” in the field. I would like to share my insights as a continuing student in the arena of wound care and coding.

When providing services and billing payers, it is best to have the latest Local Coverage Article or coverage policy. I will be using the Local Coverage Determination (LCD) (Wound Care and Debridement A52029) in my region with Noridian Healthcare Solutions Inc. (Jurisdiction J-F) as the authoritative source of rules and regulations that I will need to follow in my region. You will need to locate the contractor in your region. When we provide wound care services for patients with private insurance, the same would hold true. You should obtain the policy guidelines from that specific insurance plan when possible but often, many private payers will follow guidelines similar to those of the Centers for Medicare and Medicaid Services (CMS).

Let’s break down the LCD by sections and see what information you should study and put into practice when providing the services that the policy covers. I will use the policy guidelines to help evaluate my documentation process and in designing or revising my electronic medical record (EMR) note template in order to capture all of the documentation requirements, and support my claims filing in order to meet medical necessity.

What The Codes Say About Dressing Changes
The CPT states, “A dressing change may not be billed as either a debridement or other wound care service under any circumstance (e.g., CPT 97597, 97598, 97602).”

Medicare does not pay separately for dressing changes. It reimburses services as part of a billable evaluation and management (E/M) or procedure that often occurs on the same date of service as the dressing change. You should include all topical applications (e.g. medications, ointments and dressings) you used in the office on this date of care in the payment for the procedure or visit.

As we know, it is not appropriate to use an Advance Beneficiary Notice of Noncoverage to circumvent the issue of a bundled payment. It is only appropriate to provide an Advance Beneficiary Notice of Noncoverage for services that you expect to be denied due to the absence of medical necessity. Since the costs of the dressing change are packaged into other services billed, it would not be appropriate to use an Advance Beneficiary Notice of Noncoverage to collect payment for the dressing change.

In regard to defining medical necessity, CMS states, “Providers must document the medical necessity for all services provided. If there is no documented evidence (e.g., objective measurements) of ongoing significant benefit, then the medical record documentation must provide other clear evidence of medical necessity for treatments. The medical record must also clearly indicate the complexity of skills required by the treating practitioner/clinician.” We generally accept this to mean that the patient had a reason to come in for a visit, such as the wound requires ongoing treatment for removal of fibrin or slough, or requires debridement to allow the wound to continue to heal.

Getting Payment For Reevaluation/Reassessment Of Wounds
In general, other than an initial evaluation, the assessment of the wound is an integral part of all wound care service codes and, as such, these assessments are not separately billable. An initial wound assessment gets separate reimbursement using an E/M code. This does not require a -25 modifier in general (unless your region’s carrier states that it does).

Reassessment or reevaluation at a follow-up visit when there is no debridement but there is a dressing change is generally a non-covered routine service, or is included as part of another service provided such as cleansing of the wound with and/or without a dressing change. However, documentation may clearly support that there had been a significant improvement, decline or change in the patient’s condition or functional status that you did not anticipate in the plan of care, and requires further evaluation and a change in treatment plan. In that case, consider this separately covered and bill it with the appropriate E/M service code and/or the proper procedure code if a separate procedure was necessary to address the changing condition.

What To Include When Documenting Debridement
Pertaining to the codes for selective debridement (CPTs 97597 and 97598), supporting documentation should include the following:

• description of instruments used such as curette, high-pressure water jet, scissors, scalpel or forceps; and
• objective assessment of the wound to include drainage, color, texture, temperature, vascularity, condition of surrounding tissue, and size of the area to have debridement.
In regard to non-selective debridement (CPT 97602), supporting documentation should include:
• the type of technique utilized such as wet-to-moist dressings, enzymatic debridement or abrasive procedure; and
• objective assessment of the wound to include drainage, color, texture, temperature, vascularity, condition of surrounding tissue, and size of the area to have debridement.

I will review in more depth the definition of each of the selective and non-selective debridement codes along with the surgical debridement codes below.

There is another policy for the treatment of ulcers and symptomatic hyperkeratoses (L35461). The policy is quite clear that in order to treat an ulcer, there has to be partial thickness skin loss of either the epidermis and/or dermis, and until such loss, it is not considered an ulcer. Clinicians sometimes describe a “pre-ulcer” where there is a deep tissue injury. However, a “Wagner grade 0” would not qualify as an ulcer under this policy.Symptomatic hyperkeratosis may require paring, cutting, shaving or a more aggressive treatment by excision or destruction. However, within this ulcer treatment policy, it only addresses paring or cutting of a superficial ulcer and/or symptomatic keratotic lesion. You will need to seek out the policy that includes excision and destruction.

What The Specific Debridement Codes Include
The CPT codes 11042-11047 for surgical debridement of the ulcer not only refer to ulcer size but also to levels of the actual tissue debrided. This is based on tissue type (e.g. partial skin, full thickness skin, subcutaneous tissue, bone, muscle, etc.) of non-contiguous skin and other deeper tissue structures.

First, let us review the debridement codes before we talk about what codes to bill.

Code 11042: debridement, subcutaneous tissue. This includes the debridement of epidermis and dermis, if performed, for the first 20 cm² or less.

Code 11043: debridement, muscle and/or fascia. This includes debridement of epidermis, dermis and subcutaneous tissue, if performed, for the first 20 cm² or less.

Code 11044: debridement, bone. This covers the debridement of epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed, for the first 20 cm² or less.

Code 11045: debridement, subcutaneous tissue. This includes the debridement of epidermis and dermis, if performed, for each additional 20 cm² (list separately in addition to the code for the primary procedure).

Code 11046: debridement, muscle and/or fascia. This pertains to debridement of the epidermis, dermis and subcutaneous tissue, if performed, for each additional 20 cm². List this separately in addition to the code for the primary procedure.

Code 11047: debridement, bone. This includes debridement of epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed, for each additional 20 cm². List separately in addition to the code for the primary procedure.

Code 11055: paring or cutting of benign hyperkeratotic lesion. This pertains to corn or callus for a single lesion.

Code 11056: paring or cutting of benign hyperkeratotic lesion. This pertains to corn or callus for two to four lesions.

Code 11057: paring or cutting of benign hyperkeratotic lesion. This pertains to corn or callus for more than four lesions.

Code 97597: debridement. This pertains to the use of high pressure water jet with/without suction or sharp selective debridement (with scissors, scalpel and forceps) for an open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session of total wound(s) surface area for the first 20 cm² or less.

Code 97598: debridement. This covers high pressure water jet with/without suction or sharp selective debridement (with scissors, scalpel and forceps) for an open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session of total wound(s) surface area. It pertains to each additional 20 cm² or part thereof. List separately in addition to the code for the primary procedure.

When we report debridement codes, we will need to add up the total L x W of wounds of similar depth of tissue(s) removed and submit codes not based on the number of wounds we debrided but the number of wounds in each category or level of debridement.    

If we only debride one, we would report the debridement using the deepest level of tissue removed of that single wound. When there are multiple wounds, add the surface area of wounds that are the same depth only. Do not combine wounds of different depths.   

It pays to read the fine print. This Part A/Part B Medicare Administrative Contractor (MAC) procurement allows payment for an aggregate total of one independent tissue debridement on a given day of service. If one debrides more than four wounds on one or both feet per date of service, the policy states that it will result in a denial. You may appeal the denial with documentation justifying the additional services. This means you do not expect to perform repeat debridement for at least “several days.” This does not give us carte blanche to debride subcutaneous tissue weekly ongoing for several months. It is not expected that deeper debridement would be necessary after the first one to two thorough debridements.

Initially, we may need to debride to bone or muscle or even subcutaneous tissue, but as the treatment continues, we expect the wound to improve and debridement will become less aggressive and more superficial to a point where we would most often be performing selective debridement of fibrin and/or slough until the wound heals. However, if the wound worsens, then performing deeper debridement or a trip to the OR would be expected. We would document this in the medical record to support medical necessity.

The CMS had provided a list of ICD-9 codes that it has deemed to support medical necessity. Those ICD-9 codes that were not listed did not support medical necessity. On October 1, 2015, when ICD-10-CM codes became effective, the LCDs also started providing these codes to consider to support medical necessity. The LCD contained ICD-9 codes that supported the procedures allowed and with ICD-10 starting, the future LCDs are available and they have the ICD-9 codes converted to ICD-10 codes in these future policies.

For ICD-9-CM codes 250.80-250.83, which were diabetes with an ulcer diagnosis codes, one had to provide a secondary diagnosis code to describe the location of the ulcer and the type of ulcer (707.10-707.19, 707.8, 707.9). ICD-10-CM has similar descriptions for wound location and cause, and we will also need to include the classification of the ulcer (such as Wagner grading of DFUs or venous ulcer classification), the future LCD policies for a majority of the Medicare Administrative Contractor jurisdictions are now posted on the CMS website, and one may also access them through the American Podiatric Medical Association (APMA) Coding Resource Center (if you are a subscribing member).

When we are performing debridement of a symptomatic lesion (corn or callus), utilize the following codes based on the number of lesions debrided (CPT codes 11055-11057). The claim must have at least one of the following three diagnosis codes:
• 700 corns and callosities
• 701.1 keratoderma acquired
• 757.39 other specified congenital anomalies of skin
The claim must also have one of the following two diagnosis codes:
• 686.9 unspecified local infection of skin and subcutaneous tissue
• 729.5 pain in limb

Coding Pointers For Other Modalities
Use codes for the application of Unna boots (29580) and the application of multilayer compression system (for the leg (below knee), including ankle and foot (29581)) to provide compression in order to promote the return of blood from the peripheral veins back into the central circulation. When patients receive both debridement and an Unna boot or a multilayer compression dressing, only the debridement will get reimbursement. If one applies only an Unna boot/multilayer compression and the wound does not have debridement, then the application is eligible for reimbursement.

When using the code for MIST therapy, low-frequency, noncontact, non-thermal ultrasound (97610), note the number of topical application(s), when they were performed, wound assessment and instruction(s) for ongoing care per day. There are no designated HCPCS codes for the applicator kits one uses during a MIST Therapy treatment. These items are consumables and do not get separate reimbursement.
The CMS typically requires one to perform MIST Therapy two or three times per week to be considered “reasonable and necessary,” and the treatment duration is four to six weeks. The length of individual treatments (each session) will vary depending on wound size.

How Healthcare Reform Will Change Wound Care Reimbursement
With healthcare reform issues, we are likely to see a change in how wound care products will be reimbursed. We will see a shift toward linking payment to quality through value-based purchasing, hospital readmission rates, integrated models of care, the use of registries to report outcomes and/or tracking of healing rates, tracking costs to deliver care and the like.

When looking deeper into linking payment to data, quality and outcomes measures, the idea of using value-based healthcare aims to improve quality, lower cost and drive the system toward value in healthcare delivery. This propagates the idea that demand for value would require greater accountability on the part of all stakeholders within healthcare. Identification of best practices, providers’ adherence to best practices, measurement of provider performance, cost-effectiveness of products and procedures will be under scrutiny.

Traditional fee for service shifts to pay for quality and quality measures is how providers will get payment. Legislatively, quality measures will be tied to the Sustainable Growth Rate fix.

The Healthcare Effectiveness Data and Information Set (HEDIS) 2013 measures are an example of paying for quality, which is quite integral within the primary care setting. This is a tool more than 90 percent of payers use to measure performance on important dimensions of care and service. Additional reimbursement is available if the clinicians perform at required levels or better within the framework of the measures and as stated in their contracts.

Another payment schema that has emerged is an integrated mode of care, better known as bundled payments. This involves the use of a single payment for a defined group of services. It may cover services furnished by a single entity or items and services furnished by several providers in multiple care delivery settings. There is a single negotiated episode payment of a predetermined amount for all services required to deliver the care needed to address the condition. Payments may occur prospectively or retrospectively. There are already examples of this in the outpatient hospital wound care arena.

In 2013, CMS released the Hospital Outpatient Prospective Payment System proposed rule, which bundled the cellular and/or tissue-based products for wounds (CTPs) (skin substitutes) into the procedures reimbursed at a specified payment rate. This is akin to what we often see in the OR setting, where all items used during an operative setting are included as a bundled payment to the entire procedure. For example, one would include the screws used in the package price for repair of ankle fractures and the physician would not receive a separate fee for the screws regardless of the cost of the item. Facilities will need to review the cost of delivery of care and compare purchases to determine products they will carry and have available to providers.

There is an argument that the payments made in these bundled programs are often low and that low payments will lead to clinicians using these items (e.g. CTPs, skin substitutes) less frequently, possibly leading to decreased access for patients who are at risk for high-risk complications and morbidities.

Final Thoughts
Regardless of the ongoing discussion of future compensation models, we can take advantage of the opportunities and set our practices apart by collecting data. This involves tracking healing rates or outcomes, utilization review of products and practice guidelines based on the best available evidence and cost of delivery of care. Do not just evaluate what the product or device costs, but also perform a true cost-benefit analysis. With these data points, we can put into place a process by which we will adopt new modalities, new products and procedures as we determine how these items can help to produce acceptable outcomes. Insurance plans will monitor patient satisfaction as well when it comes time to contract with providers in the future.   

We can use our data when negotiating during plan contracting, in marketing ourselves to accountable care organizations (ACOs), in negotiations with hospitals if they are looking to purchase the practice, in negotiation with manufacturers, and in collaboration with our colleagues if we want to form supergroups and the like.   

What would I do with all this information? The first thing I would do is locate my future LCDs and use them to start implementation of ICD-10-CM. All of the future policies have the ICD-10-CM codes that are applicable to the policy so I would use this if I had not already finished my superbill conversions. Then I would move on to use these to review my EMR templates and look at my current documentation to see if I will pass the ICD-10 requirements.

Dr. Aung is in private practice in Tucson, Ariz. She is a a Certified Professional Medical Auditor and member of the American Academy of Professional Coders. She is also a panel doctor at Carondelet St. Mary’s Advanced Wound and 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 Medicine. Dr. Aung is a member of the APMA Coding Committee.    

Editor’s note: For a related article on coding, see “Does Your Documentation Have To Change For ICD-10?” on page 78 in this month’s issue.