Business Briefs: 2011 Debridement Codes Have Changed – Be Sure Your Wound Care Team Implements the Changes

Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

  In the fall 2007 In Business column of Today’s Wound Clinic, this author informed wound care professionals about several important debridement issues:

  A. The Office of Inspector (OIG) recommendations that were agreed to by the Centers for Medicare & Medicaid Services (CMS):
    • Medicare contractors should strengthen program safeguards and prevent improper payments for surgical debridement services.
    • Medicare contractors should clarify information that needs to be documented in the medical record to meet Medicare requirements.
    • CMS should implement edits pertaining to debridement services (e.g., frequency edits).
    • Medicare contractors should conduct medical reviews pertaining to debridement services.
    • Medicare contractors should educate providers regarding surgical debridement services: 1) what services are considered surgical debridement, 2) how debridement services should be coded, and 3) when modifiers may be used.

  B. Debridement local coverage determinations (LCDs)

  C. Definitions of surgical excisional debridement, selective debridement, and non-selective debridement

  D. Documentation guidelines for chronic wound debridement services

  E. Medicare payment rates for physicians and hospital-owned outpatient wound care departments

  Despite the educational efforts of this author and speaker, the educational efforts of Medicare contractors, and the educational efforts of professional wound care societies, some wound care professionals and some hospitals appeared confused and did not 1) thoroughly document their debridement services, 2) follow their Medicare contractor’s utilization guidelines, and/or 3) select the codes that properly represented the debridement services provided. These professionals and hospitals had a false sense of security when they received Medicare payments. Then as Medicare implemented more and more medical reviews, some of these professionals and hospitals faced Medicare repayments.

2011 Debridement Coding Changes

  The American Medical Association (AMA) and CMS worked for several years to solve the debridement coding dilemma. Through their efforts, the following debridement coding changes became effective on January 1, 2011.

    • “Excision” was removed from the subheading of the Integumentary Section of the CPT® codebook. It now reads “debridement”. The work is still considered a surgical procedure. Therefore, physicians should use the surgical type of service code (2) when reporting the work on their Medicare claim forms.
    • The three debridement codes (11010-11012) used when foreign material is removed associated with open fractures and dislocations have been revised to state that they should be used when debridement is performed at the site of an open fracture and/or an open dislocation.

    • The debridement of partial thickness and full thickness skin codes (11040 and 11041) were deleted. Providers are now directed to use the active wound management codes 97597 and 97598 for debridement of skin (epidermis and dermis). This is considered medical work. Therefore, physicians should use the medical type of service code (1) when reporting the work on their Medicare claim forms.
      º The description of 97597 and 97598 now includes the term “open wound”. Providers who are providing routine foot care should not use these codes for routine foot care, such as debridement of hyperkeratotic tissue.
      º Codes 97597 and 97598 are now billed in 20 sq cm increments. In prior years, only one of these codes was used per session: 97597 was used when the total surface area of all wounds debrided was less than or equal to 20 sq cm; 97598 was used if the total surface area of all wounds debrided was greater than 20 sq cm. In 2011:
        • The medical debridement code 97597 will be used for the first 20 sq cm or less of total wound(s) surface area
        • The medical debridement code 97598 became an add-on code and will be billed, in addition to 97597, for each additional 20 sq cm or part thereof, of total wound(s) surface area

  Providers should also note that 97597 and 97598 include wound assessment, topical application(s), and instructions – therefore, this work should be included in providers’ documentation.
    • The following debridement codes (11042, 11043, and 11044) were revised; they are now described by depth of tissue removed and size of surface area (first 20 sq cm or less) of the wound. Providers can no longer bill these codes per wound; they must add together the surface area of wounds that had the same depth of tissue debrided. The revised definitions also allow coding for debridement of subcutaneous tissue, muscle and/or fascia, or bone, even if epidermis and/or dermis are not present. NOTE: The previous years’ definitions of these codes required the debridement of skin plus the subcutaneous tissue, muscle, or bone.

    • Three new codes (11045, 11046, and 11047) were added to report each additional 20 sq cm, or part thereof, and are to be reported in conjunction with their respective base debridement codes (11042, 11043, and 11044).

    • The introductory guidelines of the CPT® codebook Debridement Section remind providers to select surgical debridement codes (11042 -11047) by the depth of the tissue that was removed and by the surface area of the wound. Providers are also reminded that codes 11042-11047 are for debridement of injuries, infections, wounds, and chronic ulcers.
      º Providers are to code single wounds based on depth of the deepest level of tissue removed
      º Providers are to code multiple wounds that had the same depth of tissue removed by adding the surface area of all those debrided wounds. Therefore, modifiers such as RT, LT, 50, and TA-T9 will no longer be used with the surgical debridement codes (11042-11047).

    • If providers debride more than one wound and remove different depths of tissue in each wound, they should itemize the codes for each debridement depth on the claim form.

    • The introductory surgical preparation guidelines of the CPT® codebook Skin Replacement Surgery and Skin Substitutes Section remind providers not to use 15002-15005 for removal of nonviable tissue/debris in a chronic wound (e.g., venous or diabetic) when the wound is left to heal by secondary intention. These codes should only be used when physicians remove appreciable nonviable tissue from a burn, traumatic wound, or a necrotizing infection, OR incisionally release a scar contracture.

    • Providers should continue to use the other specific debridement codes:
      11000-11001 Debridement of extensive eczematous or infected skin
      11004-11008 Debridement of necrotizing soft tissue infections
      11010-11012 Debridement of an open fracture and/or an open dislocation
      11720-11721 Debridement of nails
      15002-15005 Surgical preparation
      15920-15999 Excision of pressure ulcers
      16020-16030 Debridement of burn wound
      97602 Debridement, non selective

  Wound care providers should acquire and read the 2011 CPT® Current Procedural Terminology codebook and the 2011 CPT® Current Procedural Terminology Changes: An Insider’s View book for a complete review of all the 2011 procedure code changes. If providers have questions about the 2011 CPT® codes, they should contact the CPT® Network at www.cptnetwork.com for answers straight from the source of the CPT® codes and guidelines.

  See TABLE I for a comparison of the 2010 and 2011 debridement codes. For a physician’s perspective on the revised/new debridement codes, be sure to read Dr. Caroline Fife’s excellent article. Also be sure to visit the Today’s Wound Clinic website and test your 2011 debridement code knowledge by coding the procedures provided by Dr. Fife. This is a great opportunity to think about various coding scenarios before you actually encounter them in your wound care practice.

Medicare Payment Rates for Revised/New Debridement Codes

  Physicians: The Medicare payment rate for 11042 is slightly increased in 2011 for work performed in the office and in facilities. If physicians debride subcutaneous tissue from wound(s) whose surface area exceeds 20 sq cm, they will also receive the 11045 add-on payment.

  In 2010 two of the excisional debridement codes (11043 and 11044) were assigned a 10 day global period by Medicare. In 2011 those global periods have been removed: now all the debridement codes listed in TABLE I are assigned 0 day global periods. The removal of the global periods from 11043 and 11044 caused a reduction in their relative value units (RVUs). The reduction in the RVUs caused a decrease in the 2011 Medicare payment rate for 11043 and 11044 in the office and in facilities. Like 11042, physicians will receive the 11046 add-on payment in addition to their payment for 11043, if they debrided muscle and/or fascia from wound(s) whose surface area exceeds 20 sq cm. Similarly physicians will receive the 11047 add-on payment in addition to their payment for 11044, if they debrided bone from wound(s) whose surface area exceeds 20 sq. cm.

  Physicians should also note that the Medicare payment rate for 97597 increased for work performed in the office and decreased for work performed in facilities. Physicians are not paid for 97602.

Hospital-Based Outpatient Wound Care Departments (HOPDs)

  HOPDs (except in Maryland) are paid by Medicare based on the Ambulatory Payment Classification (APC) system group to which each CPT® code is assigned. The 2011 national average APC payment rates for 11042 ($188.16) and 11043 ($188.16) are essentially the same as they were in 2010. If the physician debrides a total surface area of subcutaneous tissue that exceeds 20 sq cm, the APC payment rate is 50% of the Medicare allowable ($94.08) for each additional 20 sq cm reported with the add-on code 11045. If the physician debrides a total surface area of muscle and/or fascia that exceeds 20 sq cm, the APC payment rate is 50% of the Medicare allowable ($94.08) for each additional 20 sq cm reported with the add-on code 11046. The 2011 national average APC payment rate increased for the debridement of bone. It is $584.96 for total surface area less than 20 sq cm (11044) and 50% of the Medicare allowable ($292.48) for each additional 20 sq cm reported with the add-on code 11047.

  The 2011 national average APC payment rate decreased by a few cents for 97597 and 97598. However, the HOPD will now be paid more when they debride wounds that exceed 20 sq cm. The APC payment rate is $103.14 for 97597 and is 50% of the Medicare allowable ($51.57) for each additional 20 sq cm reported with the revised add-on code 97598. The 2011 national average APC payment rate also increased to $62.70 for 97602.

Medical Debridements Provided to Skilled Nursing Facility Patients During the Part A Stay

  When physicians and/or HOPDs provide medical debridements 97597, 97598, and 97602 to Medicare Part A covered patients who reside in skilled nursing facilities, they must make arrangements to bill the SNF for these services. These debridements are currently considered part of the consolidated billing that the skilled nursing facilities receive for Medicare Part A covered patients.

  See TABLE II for the 2011 national average Medicare allowable rates for physicians and for hospital-based outpatient wound care departments (HOPDs). NOTE: The most commonly used chronic wound debridement codes described in TABLE I are shaded, for your convenience, in TABLE II.

Debridement Local Coverage Determinations (LCDs)

  Per the recommendations of the OIG, every Medicare contractor has released LCDs pertaining to chronic wound debridements. All wound care providers should review their Medicare contractor’s website for changes to LCDs in light of the revised/new debridement codes. At the time this column was submitted for publication all of the eleven (11) Medicare contractors that typically process debridement claims for HOPDs and for physicians released LCDs that were updated to reflect the 2011 debridement code changes.

  Providers should:
    • Print their Medicare contractor’s LCD and attachment,
    • Read the LCD and attachment, and
    • Establish an implementation plan to follow all the guidelines pertaining to indications, contraindications, coding, documentation, and utilization.

  If providers read several different Medicare contractor’s LCDs and attachments, they will quickly learn that the debridement guidelines often vary from one contractor to another. That is why providers should not rely on Medicare debridement coverage information they may receive from other providers who submit claims to different Medicare contractors.

    • For example, some contractors allow the use of 97597 for the debridement of fibrin, exudate and biofilm, while other contractors require that work to be billed as part of evaluation and management services.

    • Another example pertains to the place of service where debridement services may be performed. Some contractors will not cover specific debridement services when performed in an office setting, while other contractors will cover those debridement services in office settings.

    • A final example pertains to the frequency and total number of debridements that are covered by the Medicare contractors. Providers must read their Medicare contractors’ LCDs very carefully to ascertain their contractor’s utilization guidelines, as well as their specific documentation guidelines.

  Ever since the revised/new debridement codes were released, this author has received many calls pertaining to the three following issues:
    • Why does the CPT® codebook instruct providers to use the 59 modifier with the add-on code 11045? To the best of my coding knowledge, modifiers are not typically used with the add-on codes. Hopefully, the American Medical Association will clarify that issue for us via their monthly publication call the CPT® Assistant in the near future.

    • Is the debridement code selection to be based on the pre-debridement or post-debridement size of the wound? Several of the vignettes supplied by the American Medical Association describe measuring the size of the wound prior to debridement and then re-measuring it and recording the size post debridement. However, I cannot find an iron-clad answer to this question. Hopefully, the American Medical Association will clarify that issue for us via the CPT® Assistant.

    • If a wound only requires partial debridement, should providers measure and report the entire surface area of the wound or only the surface area of the debrided portion of the wound? This question never crossed my mind because providers are taking care of the entire wound and getting paid based on the deepest level of skin or tissue debrided. After numerous providers and coders called me with the same question, I went back to the 2011 CPT® reference books and re-read the description of the debridement codes and their clinical vignettes. I came to the same conclusion: the providers should measure the surface area of the entire wound. Realizing that my opinion does not count, I thought I might be able to find this size answer in the Medicare contractors’ revised debridement LCDs.

  Therefore, I reviewed every Medicare contractor’s LCD pertaining to the debridement codes. I learned that each contractor addressed reporting the size of wound in a slightly different way. See TABLE III (Located Only Online at www.todayswoundclinic.com/bb-debridement for a quick glance at the variety of measurement guidelines found in the Medicare contractors’ LCDs. If providers wish to have a specific answer to the partial debridement measurement question, they should send an e-mail to their respective Medicare contractor’s medical director. Providers should also watch for debridement clarifications in the CPT® Assistant.

  CAUTION: Providers should read their own Medicare contractor’s LCD in its entirety – DO NOT RELY ON THE QUICK GLANCE TABLE III TO PROVIDE YOU WITH ALL THE INFORMATION THAT YOU NEED TO MEET YOUR MEDICARE CONTRACTOR’S COVERAGE REQUIREMENTS. Providers must read every word of your Medicare contractor’s LCDs because each sentence in the LCD is very important. Providers often ask me to write a synopsis of the LCDs so they do not have to read the LCDs that pertain to their work. I always decline that request by saying “What part of the LCD don’t you want me to discuss?” Since every sentence of every LCD has a specific direction from a specific Medicare contractor, providers should feel compelled to read every word of every revision of every pertinent LCD and its attachment(s). By the time a synopsis would be written about every sentence in an LCD, the synopsis would be as long as the LCD. The moral of this CAUTION is that providers should read LCDs carefully, highlight them, make implementation notes, and then implement the various guidelines. If the LCD does not provide the answer to a “burning question”, contact the Medicare contractor medical director who wrote the LCD and seek clarification.

Summary

  Wound care providers should study the 2011 revisions to the existing debridement codes and the new 2011 debridement add-on codes. Then providers should make the appropriate changes to their charge sheets/super bills, charge description masters, etc. Be sure you understand how to bill the add-on codes (11045, 11046, 11047, and 97598) in addition to the base codes (11042, 11043, 11044, and 97597). Remember that the 10-day global periods for 11043 and 11044 were eliminated.

  Wound care physicians and wound care professionals should select the appropriate debridement code based on 1) how the procedure was performed, 2) the type of tissue that was removed, 3) the deepest level of tissue removed, and 4) the size of the wound surface area. Wound care providers should remember not to choose a debridement code because of the payment rate that is attached to it. Instead, choose a debridement code because it is the best descriptor of the work performed.

  Providers must carefully monitor their Medicare contractor’s LCDs pertaining to the revised/new debridement codes. Just because the LCDs were updated in January 2011 does not mean that they won’t be updated one or more times throughout 2011. Hopefully, the Medicare contractors and/or AMA will provide clear guidance about 1) the use of the 59 modifier when multiple debridement codes are billed, 2) billing for pre- or post- debridement wound surface, and 3) the wound surface size to report when only a portion of the wound was debrided.

  Most importantly, detailed documentation should consistently be present in the medical record to support the procedures performed and the code(s) billed. Wound care providers should be sure to meet all the documentation requirements of the Medicare contractor that processes your claims.

  Keep in mind that the various auditing organizations will use the LCD that existed on the day that you performed a service. They will compare you documentation in the medical record to the LCD requirements. If the medical record does not prove medical necessity and/or meet the LCD guidelines for debridement, providers may face a repayment to the Medicare program. Therefore, NOW IS THE TIME TO IMPLEMENT CORRECT CODING AND DOCUMENTATION FOR SURGICAL AND MEDICAL DEBRIDEMENTS.

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

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.