Medicare (Non) Coverage for Debridement: The WPS LCD and What We Really Need to Worry About

A new Local Coverage Determination (LCD) for debridement does not include diabetic foot ulcers in the list of conditions for which debridement is covered. However, the real omission may be “the wounds with no name.”

Wisconsin Physicians Service Government Health Administrators (WPS GHA), a Medicare Administrative Contractor (MAC), implemented its LCD on Wound Care on April 16, 2018. The United States jurisdictions and respective states impacted by the WPS Wound Care LCD are:

• Jurisdiction 5 (J5)—providing both Part A and Part B Medicare benefit administration for Iowa, Kansas, Missouri, and Nebraska, as well as Part A Medicare benefit administration for J5 National providers
• Jurisdiction 8 (J8)—providing both Part A and Part B Medicare benefit administration for Indiana and Michigan

The WPS Wound Care LCD removed coverage for debridement of chronic non-pressure ulcers when the severity is classified as “limited to breakdown of skin.” If physicians remove necrotic tissue, they can no longer bill an open wound debridement (e.g., 97597/97598).

We now need a history lesson. Since the 1960s, WPS Government Health Administrators has administered Medicare Part A and Part B benefits for millions of seniors in the jurisdictions mentioned above. From time to time, they have updated codes. A decade ago, we discussed what changed when new debridement codes were implemented. In 2010, the American Medical Association (AMA) Current Procedural Terminology (CPT^®) Codes for “Excisional Surgical Debridement” were:

• 11040: Partial thickness skin
• 11041: Skin and subcutaneous tissue
• 11042: Full thickness skin
• 11043: Skin, subcutaneous tissue, and muscle
• 11044: Skin, subcutaneous tissue, muscle and bone

In 2010, the AMA CPT^® Codes for non-surgical debridement of necrotic tissue (called “Selective Debridement”) were:

• 97597: Removal of devitalized tissue from wound(s), selective debridement, without anesthesia, per session; total wound(s) surface area less than or equal to 20 sq cm.
• 97598: Removal of devitalized tissue from wound(s), selective debridement, without anesthesia, per session; total wound(s) surface greater than 20 sq cm.

In other words, before 2011, the codes 97597 and 97598 were specifically for necrotic or devitalized tissue but were not considered surgical debridement. In 2011, the AMA panel deleted the codes for “skin-only” debridement (11040 and 11041) and replaced them with codes 97579 and 97598, but changed the definition of those codes. While 97597 and 97598 still represented the debridement of devitalized skin and debris, the new codes became part of the “sharp” debridement code set. The old codes—11042, 11043, and 11044—still defined debridement by depth, but were no longer billed per wound; rather, they were billed by the first 20 sq cm of wound surface area debrided and new codes were added that were paired with those codes to describe debridement of additional wound surface area at the same depth.

2011 Revision to the AMA CPT Debridement Codes:

• 97597: Debridement of open wound, i.e., fibrin, devitalized epidermis and/or dermis, exudate, fibrin, biofilm (first 20 sq cm)
• 97598: Debridement of open wound, i.e., fibrin, devitalized epidermis and/or dermis, exudate, fibrin, biofilm (each additional 20 sq cm)
• 11042: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed), first 20 sq cm or less
• 11043: Debridement, muscle (includes epidermis, dermis, and subcutaneous tissue, if performed), first 20 sq cm or less
• 11043: Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscles and/or fascia, if performed, first 20 sq cm or less

In the 2011 revision to the debridement codes, that means we lost the code for debridement of skin unless it was “devitalized.” Strictly speaking, there is no code that describes the debridement of “live” skin (which is often required over areas of undermining). However, the new WPS policy states you cannot use 97597/97598 for debridement of necrotic skin. However, since the definition of these codes is removal of “devitalized” skin, it would appear that you cannot use those codes at all.

WPS also identifies conditions that must be present and documented in order for a debridement to be covered. The list includes neuropathic and neuroischemic ulcers as being covered for debridement, but it does not specifically identify diabetic ulcers. The policy states that for debridement to be covered, at least one of the following conditions must be present and documented:

• Pressure ulcers (i.e., stage III or IV)
• Venous or arterial insufficiency ulcers
• Dehisced wounds
• Wounds with exposed hardware or bone
• Neuropathic ulcers
• Neuroischemic ulcers
• Complications of surgically created or traumatic wound

Since there is no ICD-10 code that is specific to diabetic foot ulcers (DFUs), I am not sure this is a crisis with regard to DFUs (they are coded as chronic ulcers). However, the focus of the comments to WPS has largely been over whether diabetic foot ulcers will be covered for debridement.  

What really worries me is that the policy leaves out one of the biggest categories of ulcers which I have termed, “the wounds with no name.” To be precise, they are really the ulcers with no name since they are chronic ulcers due to underlying medical conditions. They are not venous, neuropathic, or neuroischemic. They are just bad. I have been warning that “the wounds (ulcers) with no name,” one of the largest wound categories, are going to end up receiving “no care.”¹ We do not talk about them, and we do not do research on them—because they do not fit nicely into a category. It’s hard to talk about anything that does not have a name.

Ignoring the “wounds with no name” is the real threat to our continued ability to provide wound management services and is another reason that real world data are desperately needed. The U.S. Wound Registry (USWR) could provide data on the prevalence rates of various wound/ulcer types and their “natural history”; USWR data on Medicare patients can be linked to their cost data in the Medicare claims database. That is not likely to happen because there’s no funding for it. That’s a shame because all the MACs will eventually craft new LCDs on wound care and each time coverage for a service or product is removed, the LCD will include a statement about the “lack of evidence” to support it in the first place.

This is one of the many things I do not enjoy being right about. Policy makers do not understand what we actually treat any more than they understand what we actually do, and the fault is ours, not theirs.

Of note, these coverage policies are usually written in response to an apparent abuse of codes. The WPS clearly believes these codes are being billed too frequently, and it is moving to stop that practice. That might be the other thing we really need to worry about, which is the way wound management services are reimbursed. Wound management practitioners are effectively the coordinators for chronic diseases that result in wounds because wounds are a symptom of disease. The problem is that wound management practitioners have no way to be compensated for the scope and nature of the services we provide. Clinicians can, however, bill for debridement, so they do. This is a much, much larger issue, and one that no one wants to talk about.

Caroline E. Fife is chief medical officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.

This article was originally published at https://carolinefifemd.com/2019/10/07/wps-coverage-for-debridement-and-what-we-really-need-to-worry-about/. It is reprinted with permission.

1. Fife C. The wounds with no name … and the patients who will get no care. Available at  https://carolinefifemd.com/2019/06/27/the-wounds-with-no-name-and-the-patients-who-will-get-no-care/. d June 27, 2019.