Ask the Board

  In this exclusive column, TWC offers readers the chance to ask industry-related questions to our expert editorial board members.

  Q: Why are my claims for debridement of multiple wounds denied?

A: By Kathleen D. Schaum, MS

  This month, TWC received numerous questions pertaining to denied claims for both surgical and medical debridement. Most questions were similar to:

    • “I surgically debrided subcutaneous tissue from wounds on both feet: 5 sq cm on the right foot and 10 sq cm on the left foot. I billed 2 units of 11042. I was paid for only 1 unit. How should I code this claim so that I get paid for the work I performed on both feet?”
    • “I medically debrided devitalized epidermis and dermis from wounds on both feet: 8 sq cm on the right foot and 6 sq cm on the left foot. I billed 2 units of 97597. I was paid for only 1 unit. I even tried using modifier 50, but was only paid for 1 unit. How am I supposed to code this claim to receive payment for the bilateral work that I did?”

  The answers to these questions, and to all similar debridement coding questions, point to a lack of knowledge/misunderstanding about the descriptions of these debridement codes.

  Surgical debridement codes are described by and reported by the depth of tissue removed and by the surface area of the wound, not by the number of wounds debrided. If more than one wound is debrided to the same depth, qualified healthcare professionals (QHP) should add together the surface area of all debrided wounds. For example: The work described in the first question was debridement of a total of 15 sq cm of subcutaneous tissue. The QHP should have coded the claim as 1 unit of 11042 because the wound surface area did not exceed the code description of 20 sq cm. Therefore, the QHP was actually paid correctly. If the total wound surface area debrided had exceeded 20 sq cm, the QHP would have billed 1 unit of 11042 for the first 20 sq cm and 1 unit of 11045 for the additional 10 sq cm.

  Medical debridement codes are reported by the total surface area of the wound(s) debrided, not by the number of wounds debrided. For example: The work described in the second question was debridement of a total of 14 sq cm of epidermis and dermis. The QHP should have coded the claim as 1 unit of 97597 because the wound surface area did not exceed the code description of 20 sq cm. Therefore, the QHP was actually paid correctly. If the total wound surface area debrided had exceeded 20 sq cm (for example 40 sq cm), the QHP would have billed 1 unit of 97597 and 1 unit of 97598.

  QHPs should pay close attention to changes in codes, to their descriptions, and to the explanations for their use. Upon close review of the surgical and medical debridement codes, QHPs will understand that the location of the debrided wounds and the number of wounds debrided do not determine the selection of the debridement codes.

  For an in-depth discussion of debridement codes and other wound-specific codes, consider attending a 2013 Wound Clinic Business seminar: www.woundclinicbusiness.com.

For a full disclaimer regarding this information, please refer to Business Briefs in this issue.