Business Briefs: 2011 Debridement Codes and Payment: The Remaining Pieces of the Puzzle

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  Ever since the deleted, revised, and new debridement codes went into effect on January 1, 2011, this author has received hundreds of phone calls and e-mails. Some wound care providers have received incorrect guidance about the new codes. Some wound care providers have created their own debridement coding rules. Others have received claim denials that they cannot explain. Others have decided that they are always going to bill for 11042. As you know, none of these situations are appropriate for building a sound wound care business. It appears that many wound care professionals have pieces of the puzzle, but may not have pieced together the entire puzzle. Following you will find some of the most commonly asked questions pertaining to the 2011 debridement codes. After you read each question, take a few moments to silently answer each question before you read the printed answer.

  Q: Why can’t I still use 11040 and 11041? They correctly describe the debridement work that I perform in my office-based wound care practice.
  A: Effective January 1, 2011, the American Medical Association (AMA) eliminated those two surgical debridement codes. If you use these codes for dates of service on or after January 1, 2011, your claims will most likely be denied by all payers. If you wish to be paid for your work, you should use the medical debridement codes 97597/97598 and the surgical debridement codes 11042-11047 on your medical claims.

  Q: The other physicians in my group practice always commend my meticulous documentation. For example, I carefully document if I debride wounds on different anatomical locations. However, my coder will not allow me to 1) code and bill for the debridement of each location and 2) to use the –RT and –LT modifiers when I debride wounds on the right and left leg at the same visit. Will you please tell my coder that she is mistaken?
  A: Congratulations for your meticulous documentation! That will help you immensely during any type of prospective or retrospective audit. Congratulations also to your coder who is 100% correct about the 2011 debridement codes!

  In 2010 you were able to itemize for each wound that was surgically debrided: anatomic locations and right and left were important in 2010. Not so in 2011: you must sum the total square centimeters of all wounds debrided at the same depth and submit the base code for the first 20 sq cm and the add-on code for each additional 20 sq cm or part thereof. If you debride different wounds at different depths, code and bill the appropriate code for each debrided depth. For example, if you debride 15 sq cm of muscle on the left leg and 5 sq cm of bone on the right leg, you can code and bill for 1 unit of 11043 (to account for the 15 sq cm of debrided muscle) and 1 unit of 11044 (to account for the 5 sq cm of debrided bone). However, if you debride 15 sq cm of muscle on the left leg and 5 sq cm of muscle on the right leg, only code and bill for 1 unit of 11043.

  Q: My coder said that I should use the therapy codes 97597 and 97598 to code and bill when I debride devitalized epidermis and dermis. I am a physician, not a therapist. I do not want to use those codes because I often debride more than one wound during a visit and I can only bill one unit per visit for 97597 and 97598. Can I code and bill for an office visit instead?
  A: First, let me remind you that 97597 and 97598 are considered “sometimes therapy” codes by Medicare and can be used by all healthcare professionals who are qualified by their State Practice Act, by their hospital by-laws and by the payers’ coverage policies to perform medical debridement. Second, the descriptions for 97597 and 97598 were revised effective January 1, 2011. Your coder is correct that the revised descriptions clearly state that 97597 and 97598 should be used when devitalized epidermis and/or dermis are debrided.

  In 2010 wound care professionals could use 97597 if the total wound(s) surface area was less than or equal to 20 sq cm OR 97598 if the total wound(s) surface area was greater than 20 sq cm. In 2011 the medical debridement code, 97598, was changed from a base code to an “add-on” code and now reads each additional 20 square centimeters, or part thereof. Therefore, if wound care professionals medically debride wounds greater than 20 sq cm, 97598 should be billed in addition to 97597 for each additional 20 sq cm, or part thereof. Finally, if you debrided devitalized epidermis and dermis, you should bill for the medical debridement performed, not for an office visit. Remember, the basic coding rule: If a code exists, it should be used.

  Q: Some physicians in our group practice insist that square centimeters are calculated by multiplying length by width by depth. I do not believe that is correct. I was always taught that square centimeters are obtained by multiplying the length in centimeters by the width in centimeters. Please verify the correct measurement to use when reporting square centimeters debrided?
  A: A mathematician verified that square centimeters are calculated by multiplying length in centimeters by width in centimeters. Cubic centimeters are calculated by multiplying length in centimeters by width in centimeters by depth in centimeters. For clinical reasons, your physicians may wish to measure cubic centimeters, but cubic centimeters are not the correct measurement for coding and billing the total surface area debrided. The surgical and medical debridement codes are described in square centimeters.

  Q: Several of the physicians in our hospital-based outpatient wound care department (HOPD) have been measuring the entire wound and reporting the total wound surface area even if they only debrided a small portion of the wound. Therefore, the number of medical and surgical add-on codes billed is quite large. Do you have any further information regarding the proper way to measure partially debrided wounds?
  A: When the 2011 debridement codes were released, neither the Medicare contractors nor the AMA provided clear directions regarding how partially debrided wounds should be measured. For the first 5 months of 2011, the only answers that I could rightfully provide to this frequently asked question were:
    • Please check with your Medicare contractor, and
    • Please watch for further clarification from the AMA

  Fortunately, this question was clearly answered by the AMA in the May 2011, Volume 21, Issue 5 of the CPT® Assistant, the official source for CPT® coding guidance. If you do not already subscribe to this monthly newsletter, you may want to add a subscription to your reimbursement resource materials order list. The article entitled Integumentary System: Debridement clearly states that debridement codes should only be based on the measurement of the wound surface that was actually debrided. This direction will require impeccable measurement and documentation by wound care professionals when they partially debride wounds. All wound care professionals should revise their documentation format to include the measurement in square centimeters of the wound surface area that was debrided. That is the measurement that should be reported on medical claims.

  Q: Our physicians typically measure the wound size before they debride. After the debridement is completed, the debrided surface is often much larger. I think they should measure the wounds after the debridement and report the total number of square centimeters debrided. Our coder says that is not allowed. Do you have any reference source that provides guidance as to whether the medical claim should account for the size of the wound before or after debridement?
  A: As stated in the question above, wound care professionals did not receive clear guidance, from their Medicare contractor or from the AMA in January 2011, for measuring the size of the debrided wound surface. Luckily, this question and several other questions were answered in the above mentioned May 2011 issue of the CPT® Assistant. The AMA clearly states that when the entire wound is debrided, the wound measurement after debridement should be reported. Therefore, when wound care professionals debride the entire surface of a wound, they should measure the wound before and after debridement. The after debridement measurement should be used to select the correct base code and add-on codes, if required, that will be reported on the medical claim.

  Q: I am a surgeon who frequently debrides muscle and bone in the operating room. I have noticed a significant drop in my Medicare payments. Someone told me the decrease was because the 10-day global period was reduced to a 0-day global period. Is that true? If yes, were the Relative Value Units (RVUs) assigned to 11043 and 11044 revised?
  A: As a surgeon, you are very familiar with the up-front payments received for surgical procedures assigned 10 and 90-day global periods by Medicare. When those global periods are reduced, the RVUs decrease because less work is built into the code. That is exactly what happened on January 1, 2011: the 10-day global periods for 11043 and 11044 were reduced to 0-days. The RVUs were revised and the Medicare payment rates dropped. When you debrided muscle in the operating room in 2010, the Medicare allowable was $230.82 for each debrided wound. In 2011, the Medicare allowable is $122.32 for the first 20 sq cm of muscle debrided and $38.05 for each additional 20 sq cm or part thereof of muscle debrided. Likewise, when you debrided bone in the operating room in 2010, the Medicare allowable was $319.32 for each debrided wound. In 2011, the Medicare allowable is $212, 35 for the first 20 sq cm of bone debrided and $66.25 for each additional 20 sq cm or part thereof of bone debrided.

  Q: As a podiatrist, the debridement codes that I used most frequently, in previous years, were 11040 and 11041, debridement skin, partial and full thickness. Now that those codes are deleted, the medical debridement codes 97597 and 97598 describe most of the work that I perform for chronic wounds. Will you please tell me how the Medicare payments for the medical debridement codes compare to the deleted surgical codes for work performed in my office as well as in the HOPD?
  A: Following is a comparison between the 2010 and 2011 physicians’ national average Medicare payment rates for debridements performed in HOPDs. To determine the business impact of the surgical and medical debridement code changes, podiatrists and physicians should consider the wound sizes that they typically debride.

  As you know, podiatrists and physicians are paid a higher rate for procedures performed in their office because they incur the cost for the support staff, for the medical implements, and for the dressings. When evaluating the following in-office Medicare allowable rates, podiatrist and physicians should once again consider the wound sizes that they debride in their office.

  Q: As the program director in a HOPD, I do not think there is much difference in the Medicare allowable rate for the deleted surgical debridement codes, 11040 and 11041, and for the medical debridement codes 97597 and 97598. Am I correct?
  A: You are correct that the national average Medicare allowable rates for the deleted surgical debridement codes and the medical debridement codes are quite similar. In 2010 the HOPD Medicare allowable rate was the same for 11040, 11041, 97597, and 97598: $103.63. In 2011 the Medicare allowable rate is $103.14 for 97597. If the debrided portion of the wound is greater than 20 sq cm, the HOPD is paid 50% of the $103.14 for each additional 20 sq cm or part thereof.

  Q: In our HOPD the physicians often 1) write orders for the wound care staff to apply an enzymatic debridement ointment and teach the patient how to apply the debridement ointment at home, and 2) provide the patients with prescriptions to obtain the debridement ointment for patient use at home in between visits to the outpatient department. The physicians typically code and bill for an evaluation and management visit. Our coders told us that the HOPD should bill for the debridement with the enzymatic debridement ointment. I thought that we had to bill a clinic visit to match the physicians’ bills. Who is correct?
  A: Your coders deserve a big “thank you” because they are correct. When physicians perform work that meets the evaluation and management guidelines and that is not included in a pre-, intra-, and post operative procedure, they should code and bill the appropriate level of evaluation and management. When your HOPD staff receive orders to perform work such as applying Unna boots (29580), applying multi-layer high compression bandage systems (29581), and applying enzymatic debridement ointments and educating the patient how to apply the debridement agent at home (97602), the HOPD should use the code that represents the work that they actually performed. Therefore, as long as the physicians did not surgically or medically debride the same wound, the HOPD should code and bill 97602 for the scenario that you described. The physician correctly coded and billed for evaluation and management. NOTE: Physicians and HOPDs are not required to code and bill the same code when they did not perform the same work.

  While consulting with HOPDs this year, I have been surprised that many of them did not have 97602 on their charge sheets and Charge Description Masters. This code was assigned to a Medicare payable Ambulatory Payment Classification (APC) group for at least 5 years. In 2010 the APC allowable rate was $59.10. The allowable rate for 97602 increased to $62.70 in 2011.

  Q: In January I correctly transitioned to coding 97597 and 97598 when I debrided devitalized epidermis, dermis, exudate, debris, and biofilm. When I debrided more than 20 sq cm, my office manager told me that 97597 was denied on all of my claims: only 97598 was paid. Why would Medicare pay for the add- on code and not for the base code?
  A: In 2010 both 97597 and 97598 were base codes. If the debrided surface was less than 20 square centimeters, 97597 was the correct code. If the debrided surface was greater than 20 square centimeters, 97598 was the appropriate code. In 2010 if a provider mistakenly reported 97597 and 97598 on the same claim, the Correct Coding Edits denied 97597.

  For some unknown reason, the Correct Coding Edits were not updated on January 1, 2011 to take into consideration the revision of 97598 to an add-on code. When health care professionals debrided surfaces greater than 20 square centimeters and reported 97597 and 97598, they should have been paid for both codes. Unfortunately, the Correct Coding Edits caused one of 2 things to occur:

  1. The claims were denied because both 97597 and 97598 were on the claim, or
  2. The base code 97597 was denied and only the add-on code 97598 was paid

  Once some of the contractors realized the problem and learned that the Correct Coding Edits were going to be corrected on the April 1, 2011 quarterly update, they held claims with both 97597 and 97598. When they processed the claims after April 1st, the claims were correctly paid.

  If your contractor did not hold your claims until after the Correct Coding Edits were revised on April 1st, you should re-file those incorrectly denied claims, if your documentation and photographs support the use of 97598.

  Q: Since January 1, 2011 I submitted numerous claims to Medicare that requested payment for multiple units of the surgical and medical debridement add-on codes. I have usually been paid for 1 add-on code and have been denied for the others. I thought physicians were supposed to be paid for each additional 20 sq cm or part thereof. Did I misunderstand?
  A: Another set of Medicare edits, the Medically Unlikely Edits (MUEs), set the maximum number of units of service that are allowable under most circumstances for a single code to be billed by a provider on a single date of service for a single beneficiary. Medicare publishes some of the MUEs and maintains, for their internal use only, some other MUEs that are not published. For example, Medicare currently has the MUE set as a unit of 1 for both the surgical and medical debridement base codes. That makes perfect sense, because these codes are no longer paid “per wound.”

  However, Medicare is silent about the MUEs for surgical and medical debridement add-on codes. You and other wound care physicians and HOPDs have reported denied claims when multiple units of the add-on codes were submitted. Some Medicare contractors may have unpublished MUEs. If multiple add-on codes are medically reasonable and necessary, providers should check with their Medicare contractor to determine how they should report them on medical claim forms. Some contractors may advise you to simply list the number of units performed for the add-on code. Other contractors may advise you to list the multiple add-on codes, with modifier -59, on separate lines.

Coverage for Debridement:

  Between the pieces of the puzzle that you had before you read this article and the additional puzzle pieces that you acquired by reading the article, your debridement puzzle should be nearly complete. Now you should obtain the remaining pieces of the puzzle from the medical policies of the Medicare contractor that processes your claims, from the major private payers of your patients, and from your State Medicaid program. The payers may have specific coverage guidelines pertaining to covered diagnoses, covered places of service, covered providers of service, frequency of debridement, maximum number of debridements, and documentation requirements. Wound care professionals should take the time to understand the coding, payment, and coverage guidelines pertaining to surgical and medical debridement for two very important reasons: 1) they are the pieces of the puzzle that determine “if” and “how much” wound care professionals will be paid; and 2) they are the pieces of the puzzle that will help wound care professionals keep the money they were paid when they undergo audits. Take the time to gather all the debridement puzzle pieces and to completely build the debridement puzzle into your wound care practice.

Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleendschaum@bellsouth.net.

Reference

1. CPT is a registered trademark of the American Medical Association.