An Auditor’s Perspective of Debridement and E&M/Clinic Visits With Modifier -25

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure information accuracy. However, HMP Communications and the authors do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying information accuracy lies with the reader.

Because this author has taught many seminars pertaining to the importance of thorough documentation and to accurate code selection in wound/ulcer management, this article may sound like a broken record. However, the high volume of pre-payment and post-payment audits and repayments in wound/ulcer management businesses indicates the necessity to repeat some of the most important documentation components that are missing and code selection errors that are uncovered by internal and external auditors.

First, we will address some general documentation requirements. Then we will address the debridement definitions the Medicare Administrative Contractors (MACs) and auditors expect wound/ulcer management professionals to follow. That will be followed by the debridement documentation expected by the MACs and the auditors. Then the article will conclude by reviewing the coding guidelines that the MACs and the auditors expect wound/ulcer management professionals to follow when a minor procedure is performed.

General Documentation Requirements

1. Ensure that reviewers can easily identify and see the history of treatment for each of the patient’s wounds.

2. Transfer care appropriately during the global period. Almost all wound/ulcer management procedures performed (e.g., debridements, applications of cellular- and/or tissue-based products [CTPs] for skin wounds) are assigned 0-day global periods on the Medicare Physician Fee Schedule Relative Value File.¹ These global periods do not pertain to hospital owned outpatient wound/ulcer management provider-based departments (PBDs). However, they do pertain to 1) surgeons who transfer part or all of the postoperative care of their patients to another physician or other qualified healthcare professional (QHP), and 2) to the physician or QHP who provides the postoperative care transferred to them. When a surgeon wishes to transfer part or all the postoperative care to another physician/QHP, the surgeon should present that physician/QHP with a formal transfer such as a transfer order, letter, or form. Both the surgeon and the physician/QHP should document the exact day the physician/QHP first sees the patient. Appropriate modifiers should be reported by both the surgeon and the physician/QHP: the surgeon should append modifier -54 to the surgical code; the physician/QHP receiving the transfer should append modifier -55 to the same surgical code. Then Medicare will 1) pay the surgeon for the surgical procedure and the immediate post-op care she/he provided, and 2) pay the physician/QHP for the post-op care she/he provided.

3. Document the guidelines used to derive reported evaluation and management (E&M) codes and clinic visit codes. Physicians/QHPs should document whether they are using the 1995 or 1997 E&M guidelines. PBDs should create a clinic visit level mapping tool and a policy and procedure for use of the tool.

4. If you use an electronic health record (EHR), verify that the system does not automatically pull forward medications that are discontinued, diagnoses and conditions that are resolved, and treatments of previously healed conditions. Many EHRs pull forward a huge amount of information that is not relevant to the current encounter.

5. For established patients, document the results of any previous treatment. Wound progress should be documented at each encounter. Medicare will not continue to reimburse a therapy if it does not seem to be working in the wound. If the patient is referred from another physician/QHP, the referring provider should send the medical records that outline what treatment was rendered thus far and an explanation of previous treatments that were successful or that failed.  

6. Diabetes Type 1 or 2, as well as how the underlying disease is being monitored, should be documented in the medical record.

Definitions of Wound/Ulcer Debridement

Wound/ulcer management professionals should remember the following practical issues regarding debridement definitions.

• Debridement is defined as the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound/ulcer until surrounding healthy tissue is exposed.

• Providers should select a debridement method most appropriate to the type of wound/ulcer, the amount of devitalized tissue, the condition of the patient, the setting, and the provider’s experience.

• Debridements of the wound(s)/ulcer(s), if indicated, must be performed judiciously and at appropriate intervals. With appropriate care, wound/ulcer volume or surface dimension should decrease by at least 10 percent per month, or the wound/ulcer will demonstrate margin advancement of no less than 1 mm/week. Interim outcomes should be established for the wound/ulcer. These short-term goals help the clinician recognize wound/ulcer improvement and serve to confirm the patient's healing response. Medicare expects the wound/ulcer management treatment plan to be modified if appropriate healing is not achieved.

• The original debridements are typically true surgical debridements. Repeated debridements are not the same service as the original debridement service.

• Once the initial debridement of muscle and/or bone has been performed, there typically is no true necrotic muscle or bone remaining. Subsequent surgical debridement of muscle or bone is usually not necessary. If the medical record demonstrates complicating factors are present that contribute to further necrosis of muscle or bone, then subsequent staged surgical debridement of muscle and/or bone may be deemed necessary. The medical records should indicate the complicating factor(s) and the medical management used to control these complications. Staged debridement of muscle and/or bone greater than two additional debridements, should raise the question of whether the complicating factors are controlled adequately. Further debridement of muscle and/or bone may not be justified without adequate control of the underlying condition(s) leading to the complicating factors (i.e., infection, abscess, vascular insufficiency, nutritional compromise, etc.).

Surgical Debridement (CPT^® codes 11042-11047)²

Sharp debridement is technically not considered surgical debridement. When the sharp debridement term is used, it often leads auditors to look at whether the service performed is an 11042 or a 97597.

• Surgical debridement usually includes the removal of healthy tissue to ensure a clean wound/ulcer bed.

• Surgical debridement occurs only if subcutaneous tissue, muscle, or bone have been debrided/removed.

• Surgical debridement includes going slightly beyond the point of visible necrotic tissue until viable bleeding tissue is encountered. The use of a sharp instrument does not necessarily substantiate the performance of surgical debridement. Unless the medical record shows that a surgical debridement has been performed, debridements should be coded with either selective or non-selective codes (97597, 97598, or 97602).

• Surgical debridement codes, as performed by physicians/QHPs licensed by the state to perform those services, are reported by depth of tissue removed and by surface area of the wound. These codes can be very effective but represent extensive debridement, often painful to the patient, and could require complex, surgical procedures and sometimes require the use of general anesthesia. It is frequently used for deep tissue infection, drainage of abscess or involved tendon sheath, or debridement of bone.

Selective Debridement (CPT^® codes 97597 and 97598)

• The definition of CPT codes 97597 and 97598 is: Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool.

• High pressure water jet lavage (non-immersion hydrotherapy) is an irrigation device, with or without pulsation used to provide a water jet to administer a shearing effect to loosen debris, within a wound/ulcer. Some electric pulsatile irrigation devices include suction to remove debris from the wound after it is irrigated.

• Conservative sharp selective debridement (with scissors, scalpel, and forceps) is a minor procedure that refers to the removal of specific, targeted areas of devitalized or necrotic tissue from a wound/ulcer along the margin of viable tissue. Occasional bleeding and pain may occur. The routine application of a topical or local anesthetic does not elevate selective debridement to surgical debridement.

• Selective debridement should only be performed under the specific order of a physician and is typically performed in an office setting or at the patient’s bedside.

• CPT codes 97597 and/or 97598 are typically used for recurrent wound/ulcer debridements. They are not limited to any specialty and should not be reported in conjunction with CPT codes 11042–11047 and 97602. Application and removal of dressings to the wound/ulcer and patient/caregiver instructions are included in the work and practice expenses of 97597, 97598 and should not be billed separately. If a simple dressing change is performed without any selective debridement, as described by these codes, do not bill the codes to describe the dressing change.

Documentation of Wound/Ulcer Debridement

Next, we will address the specific debridement documentation requirements. When wounds/ulcers require debridement, providers should follow Medicare’s extensive documentation requirements. When indicated, wound/ulcer management in the absence of these measures does not meet coverage criteria and is not considered to be medically reasonable and necessary. Therefore, the documentation in the medical record should be legible, should support medical necessity, and should include a plan of care containing treatment goals and physician follow-up. The provider must keep on file all documentation supporting billed services and the documentation must be made available to the MAC upon request. The minimum requirements for Medicare documentation of debridement services are:

• Tissue removed (e.g., epidermis, dermis, subcutaneous tissue; muscle and/or bone)

• Method used to debride (e.g., hydrostatic, sharp instrument, or abrasion)

• Character of the wound before and after debridement including:
o Dimensions
o Description of necrotic material present
o Description of tissue removed
o Degree of epithelialization

• Evidence of the progress of the wound’s response to treatment at each physician visit, to include at a minimum:
o Total surface area (in square centimeters) and depth, tunneling
o Drainage (color, amount, consistency)
o Swelling
o Pain
o Presence (and extent of) or absence of obvious signs of infection
o Presence (and extent of) or absence of necrotic, devitalized or non-viable tissue
o Other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown

NOTE: It is not medically reasonable or necessary to continue a given type of wound/ulcer management if evidence of improvement cannot be shown. A wound/ulcer that shows no improvement after 30 days requires a new approach, which may include physician/QHP reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound/ulcer healing, or a new treatment.

• All applicable adjunctive measures employed as part of comprehensive wound/ulcer management. Adjunctive measures include but are not limited to appropriate control of complicating factors such as:
o Pressure (e.g., offloading, padding, and appropriate footwear)
o Infection
o Vascular insufficiency
o Metabolic derangement and/or nutritional deficiency

Correct Coding for Evaluation and Management/Clinic Visit with Modifier -25

Evaluation and Management/Clinic Visit codes are only intended to report separately identifiable conditions and are included in minor procedures. Therefore, E&M and Clinic Visit codes should not be reported when a minor procedure was performed during the same encounter unless the physician/QHP also addressed a new or separately identifiable problem and thoroughly documented it. (Stating in the medical record that services were greater than normal does not justify an E&M code.) If a new or separately identifiable problem was addressed when a minor procedure was performed, the E&M or Clinic Visit code should be appended with modifier -25.

The 2020 National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services provides clear instructions for the appropriate use of modifier -25:

“If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure … In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.

“Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.

“For major and minor surgical procedures, postoperative E&M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package as are E&M services related to complications of the surgery.

“Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed unless related to a complication of surgery may be reported separately on the same day as a surgical procedure with modifier 24 (‘Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period’).”

Suggested Topics for Self-Audits

Wound/ulcer management professionals and providers should conduct self-audits of topics that MACs and other auditors typically audit. The results of the self-audits should immediately identify documentation and coding errors that should be refined. The list of topics that could be audited is extensive. Following are a few audit topics that relate to the documentation and coding guidelines presented in this article:

• Verify if diagnosis codes reported on claims justify medical necessity for work performed

• Identify if debridement documentation aligns with debridement codes reported on claims (11042–11047 vs. 97597–97598)

• Determine if PBD clinic visit codes align with the clinic visit mapping tool and the PBD’s policies and procedures for the use of the tool

• Review all patient encounters for which an E&M code and modifier -25 were reported on the same day that a minor procedure was performed

• Print your medical record to verify that the documentation tells the story of each wound/ulcer, and that each procedure performed is fully documented

• Audit PBD documentation and coding, as well as physician/QHP documentation and coding

• Identify if both the PBD and the physician/QHP follow the new vs. established patient’s documentation and coding guidelines

Summary

Now that you see the guidelines that the MACs and auditors use, you should better understand the necessity for thorough documentation and appropriate code selection. To verify if your business aligns with these guidelines, use the self-audit section of this article to perform self-audits of your medical records and your code selection. Then you should pass external audits with flying colors!

Donna Cartwright is senior director of health policy and reimbursement at Integra LifeSciences Corp., Plainsboro, NJ. She is approved as an AHIMA-approved ICD-10-CM/PCS trainer and she has been designated as a fellow of the American Health Information Management Association.

1. Medicare Physician Fee Schedule Relative Value Files: https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-relative-value-files/2020 . Select RVU20A. Last accessed March 18, 2020.
2. CPT is a registered trademark of the American Medical Association. All rights reserved.
3. CMS Correct Coding Initiative 2020: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd .
4. CGS Local Coverage Determination (LCD): Debridement Services (L34032): https://tinyurl.com/rtjfg7d .
5. Palmetto Local Coverage Determination (LCD): Wound Care (L37166): https://tinyurl.com/v2otr2b  .
7. NGS Local Coverage Determination (LCD): Debridement Services (L33614): https://tinyurl.com/vladwwj  .
8. Novitas Local Coverage Determination (LCD): Wound Care (L35125): https://tinyurl.com/yxy2kahb .
9. WPS LCD# L37228 Wound Care A55909 Wound Care Companion Article for Wound Care L37228: https://tinyurl.com/sx3vnkl .
10. A55909 Wound Care Companion Article for Wound Care L37228: https://tinyurl.com/uvhsz7r.