Please Help Coding Debridement

[Hopp]

Wondering if someone would be kind enough to help with following:
Debridement skin and muscle of massive sacral decub ulcer 15 x 15 cm
I orig. coded 11043 along with 11046 x 10 and was denied on the 11046 stating this many not allowed so just wondering should I have coded procedure
Thanks in advance for help with this
Deb, CPC

[cynthiabrown]

Deb, i have a terrible time with debridement codes as well.................have you sent in dictation???

[pwarman]

What place of service are you using? Those codes are not used in an office setting. Otherwise I would have coded the same way you did. I would appeal & send the notes to prove the size. pw

[pwarman]

What place of service are you using? Those codes are not used in an office setting. Otherwise I would have coded the same way you did. I would appeal & send the notes to prove the size. pw

[Hopp]

Place of Service was hospital - Just wondering if I have to code 11403 then 11406 and then 11406-59 each separate time indicating another 20sqcm like 10 times to equal the whole total 225cm??
Any other input would be appreciated
Deb, CPC

[espressoguy]

Originally Posted by Hopp

Place of Service was hospital - Just wondering if I have to code 11403 then 11406 and then 11406-59 each separate time indicating another 20sqcm like 10 times to equal the whole total 225cm??
Any other input would be appreciated
Deb, CPC

You have coded this correctly (other than the math error - 225 sq cm wound = 11043 + 11046 x11). Some payors will accept units and some want separate lines. What I believe is happening here is that your payor is objecting to the size of the wound. I agree with what pwarman says in that you should appeal this. Your case will be made stronger if your provider took pictures documenting the size of the wound.

[Hopp]

Thanks so much for all of your help - Guess will try to appeal and use operative notes
Deb, CPC

[Grintwig]

Originally Posted by pwarman

What place of service are you using? Those codes are not used in an office setting. Otherwise I would have coded the same way you did. I would appeal & send the notes to prove the size. pw

I agree the codes you have used are right but I disagree with the bolded part of the statement these codes are usable in the office setting. My physicians do this in the office all of the time. I code them a lot for office setting and they always pay.
I have found that with the larger size wounds the insurance usually denies after a certain amount of codes (usually they deny the lines as duplicates) and we have to send notes to get the denied lines paid.
Some insurances also do want the -59 modifier on the additional lines even though you are not supposed to use modifiers on add-on codes.

[Monika Liddle]

I agree with Grintwig - you can bill debridements in the office setting. We have billed them in the office setting before and have gotten paid. For large debridements, we usually get denial and send in the medical records supporting the size of the debridement.

[BLOWRIE]

I've read in CMS guidelines, that the add on codes for debridement have a limited number that can be billed per year per Medicare patient. But it also stated that claims would be looked at on a individual basis if you surpassed that amount. I agree, appealling the claim with documentation is the best way to go.