Test Your Knowledge of Debridement Coding, Coverage, & Payment

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 author 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.

Even though it has been nearly seven years since the American Medical Association revised the Current Procedural Terminology (CPT^®) codes for surgical and active wound management debridement, wound care professionals, coders, and provider-based departments (PBDs) continue to incur denied claims and/or claim repayments for debridement services. That said, let’s take some time to conduct a self-test with this edition of Business Briefs. Feel free to offer the following test to all wound care professionals, coders, and billers in your office, PBD, and network. The self-test is worth 100 points. (Give yourself 2 points for every correct answer and 3 points for every correct explanation of your answer.) All answers and explanations are provided in this article. 

Now, let’s discuss the answers as well as the debridement coding and coverage rules that pertain to the scenarios in the self-test.

No. 1: 11042 is defined as “debridement, subcutaneous tissues (includes epidermis and dermis, if performed), first 20 sq cm or less.” Therefore, if the epidermis and dermis are missing, the physician can report 11042 if subcutaneous tissue is removed. The answer is False.

No. 2: Wound debridements (11042-11047) are reported by the depth of tissue removed and by surface area of the wound. Because bone was not debrided, 11044 should not be reported. This debridement should be reported as 97597, if permitted by the respective payer. The answer is False.

No. 3: The debridement code 11042 requires the debridement of subcutaneous tissue and can include epidermis and dermis, if performed. The debridement of devitalized epidermis and/or dermis alone is included in the definition of the active wound management debridement codes 97597/97598. The answer is False.

No. 4: Because wounds often increase in size after debridement, most payers expect the physician to measure the post-debridement size of the wound. The answer is False.

No. 5: When performing debridement of a single wound, wound care professionals should report the depth using the deepest level of tissue removed. Therefore, the wound care professional should code this as subcutaneous debridement 11042 and add-on code 11044. The answer is False.

No. 6: When debriding multiple wounds, sum the surface area of those wounds that are at the same depth. Because subcutaneous tissue was debrided from both wounds, the wound care professional should add the square centimeters debrided from each wound (20 sq cm + 20 sq cm = 40 sq cm) and report 11042 and the add-on code 11044. The answer is False.

No. 7: Wound care professionals can only bill for a procedure when it is performed. Because this wound care professional did not perform an active wound management debridement, he/she cannot bill for 97597. Instead he/she should bill for the appropriate level of E/M service documented and performed. The PBD was correct to bill for 97602 because the staff debrided the wound with the enzymatic debridement ointment. The answer is False.

No. 8: Even though both of these wounds were on different anatomic locations, bone was debrided from both wounds. Therefore, the wound care professional was correct to report 1 unit of 11044 for the 14 sq cm of bone debrided at that encounter. The answer is True.

No. 9: Because the wound care professional debrided different types of tissue from different wounds, the wound care professional was correct to code 1 unit of 11042 for the 20 sq cm of subcutaneous tissue debrided from the leg and 1 unit of 11043 with Modifier “-59” for the 6 sq cm of muscle on the other leg. The answer is True.

No. 10: In 2011, the word “excision” was removed from the debridement section of the CPT manual. The guidelines made it perfectly clear that debridement codes should be selected by the depth of the tissue removed and by the surface area of the wound. The answer is False.

No. 11: Debridement codes are not selected based on the tool used to perform the work. As previously stated, debridement codes are selected by the depth of tissue removed and by the surface area of the wound. Additionally, the surgical preparation codes 15002-15005 have seven clear guidelines, none of which pertain to the tool used. The answer is False.

No. 12: The CPT manual includes seven guidelines for 15002-15005. One of the guidelines states that 15002-15005 describe the services related to preparing a clean and viable wound surface for placement of a graft, flap, skin replacement, skin substitute, or negative pressure wound therapy (NPWT). Another guideline states the patient’s condition may require the closure or application of the graft, flap, skin replacement, or skin substitute to be delayed, but in all cases, the intent is to include these treatments or NPWT to heal the wound. A third guideline instructs the user to preclude reporting codes 15002-15005 for removal of nonviable tissue/debris in a chronic wound (eg, venous or diabetic) when the wound is left to heal by secondary intention. Another guideline directs the user to report the active wound management codes (97597-97598) and debridement codes (11042-11047) for the service described in the third guideline. The answer is False.

No. 13: Debridement codes are no longer described with the terms “partial thickness” or “full thickness.” Therefore, use of these terms to describe the debridement performed does not lead to code selection. The answer is False.

No. 14: When wound care professionals debride the same depth of tissue, they should sum the surface area of those wounds. Because 30 sq cm of muscle were debrided in this scenario, the wound care professional should report 1 unit of 11043 for the first 20 sq cm of debrided muscle and 1 unit of 11046 for the second 10 sq cm of debrided muscle. The answer is False.

No. 15: Wound care professionals must review their MAC’s local coverage determinations (LCDs) to determine the coverage guidelines for codes 15002-15005. Some contractors do not cover 15002-15005 prior to application of CTPs. Some contractors cover 15002-15005 prior to the first application of CTPs. Some contractors are silent about this topic, which means coverage will be based on documentation of medical necessity. The answer is False.

No. 16: Most MACs have debridement documentation requirements clearly described in their LCDs. For example:

• size of wound surface to be debrided
• size of wound surface after debridement
• anesthesia used (if any)
• instrument used (scissors, scalpel, forceps, water jet)
• level of tissue removed (epidermis, dermis, subcutaneous tissue, muscle, bone, fibrin, slough, etc.)
• blood loss or fluids replaced
• complications (if any, describe)
• dressings applied
• compression, offloading, etc.

The answer is False.

No. 17: The CPT manual states that wound care professionals should report the deepest level of tissue removed when debriding the entire wound. Because this wound care professional debrided the entire surface of a 40-sq cm leg wound (20 sq cm of subcutaneous tissue and 20 sq cm of epidermis/dermis), he/she should report 1 unit of 11042 for the first 20 sq cm and 1 unit of 11045 for the second 20 sq cm. The answer is False.

No. 18: Debridement codes are described by square centimeters, not by percentage. Therefore, wound care professionals should measure the debrided wound surface in square centimeters. The answer is False.

No. 19: Because the wound care professional only debrided 110 sq cm of slough from the 210-sq cm venous ulcer, he/she correctly coded 1 unit of 97597 and 6 units of 97598. The answer is True.

No. 20: Wound care professionals must document all work performed at each encounter. In addition, if a procedure code exists, it must be used. Finally, a wound care professional should not select codes to report based on the payment rate he/she prefers. The answer is False.