Documentation Causes Debridement Dilemma

Get your physicians to document correctly or leave money on the table.

By Holly J. Cassano, CPC
To be descriptive enough to create a clear picture of the procedure performed, debridement documentation in the outpatient setting must describe:
Method of debridement—The most common methods include:

• Wet-to-dry dressings. Wet dressings are applied to the wound and allowed to dry. When the dry dressing is removed, it pulls off the dead tissue.
• Application of medications that contain enzymes to dissolve dead tissue.
• Application of medicated dressings.
• Whirlpool baths.
• Surgical debridement with scalpel or scissors to remove dead tissue (the focus of this article).

CPT® section notes, “Removal of Infected/Devitalized Tissue—(11040-11044),” describes surgical debridement as:
“The physician surgically removes necrotic or dead skin. The physician uses a scalpel or dermatome to remove a superficial layer of affected skin. The epidermal layer is removed with the underlying dermis remaining intact. The partial thickness of skin is excised until viable, bleeding tissue is encountered. A topical antibiotic is placed on the wound. A gauze dressing or an occlusive dressing may be placed over the surgical site.”
Depth of debridement—Did the provider debride beyond the dead or damaged tissue down to healthy, viable tissue?
Whether the debridement was excisional or non-excisional

• Excisional debridement—Cutting away necrotic, devitalized tissue or slough to the level of viable tissue using a sharp instrument (i.e., scalpel, scissors, etc.).
• Non-excisional debridement—The removal of necrotic, devitalized tissue or slough by means of scraping, mechanical brushing, flushing, or washing (i.e., irrigation; whirlpool); minor re-moval of loose fragments.

Instrumentation—Did the health care provider use a scalpel or scissors? Use of a scalpel or blade is a better indication an excisional debridement was performed. Scissors may be used to cut away loose fragments, which is not indicative of excisional debridement. Code assignment cannot be based solely on the instrumentation, but instrumentation does assist in describing how the debridement was done.
Always remember that if the documentation is unclear, you must to query the physician for clarification.

Separate Services May Be Coded Separately

By CPT® rules, debridement excludes:

• Burn debridement or treatment (16000-16035)
• Dermabrasions (15780-15783)
• Nail debridement (11720-11721)

You may report separately any of these excluded services.
Individual payers may offer more specific instruction about what’s excluded from debridement. For example, the following is from First Coast Services Options, Inc. (FCSO) Medicare:
“FCSO does not consider the following services to be wound debridement:

• Removal of necrotic tissue by cleansing, scraping (other than by a scalpel or a curette), chemi-cal application, and wet-to-dry dressing.
• Washing bacterial or fungal debris from lesions.
• Removal of secretions and coagulation serum from normal skin surrounding an ulcer.
• Dressing of small or superficial lesions.
• Removal of fibrinous material from the margin of an ulcer.
• Paring or cutting of corns or non-plantar calluses. Skin breakdown under a dorsal corn that begins to heal when the corn is removed and shoe pressure eliminated is not considered an ulcer and does not require debridement unless there is extension into the subcutaneous tissue.
• Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, or destruction of warts. Providers should report these procedures, when they represent covered, reasonable and necessary services, using appropriate CPT® or HCPCS codes.”

Check with your individual payer(s) for any specific debridement coding requirements it may stipulate.

Not Every Service May Be Reported Independently

Active wound care codes 97597-97606 are for removing devitalized and/or necrotic tissue from wounds to promote healing, only when treating the surface skin of a wound, and are not billed in addition to debridement (11040-11044). Codes 97597-97606 generally are reported by non-physicians for selective and nonselective debridement procedures.
Remember also skin debridement that is preparatory to further surgery should not be coded as a separate procedure when debridement of an open fracture site is performed. Skin debridement is considered inherent for this procedure.
Consider the following coding example: A 75-year-old patient with type II uncontrolled diabetes presents to the emergency department (ED) with diabetes with peripheral circulatory disorders. During the exam, the ED physician discovers cellulitis of the right lower leg with small areas of necrotic tissue surrounding several wounds measuring 4 cm in total. The physician decides to perform a partial thickness debridement of and around the infected tissue with a scalpel. He measures the total area after the procedure and indicates the wound is now 5.5 cm, applies a topical antibiotic and a dressing, and orders a course of high-dose IV antibiotics to start in the ED.
You would report:

99284-25 Emergency department visit for the evaluation and management of a patient, which requires 3 key components; A detailed history; A detailed examination; and Medical decision making of moderate complexity. -Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

682.6 Other cellulitus and abscess; leg, except foot

250.72 Diabetes with peripheral circulatory disorders

443.81 Peripheral angiopathy in diseases classified elsewhere

11040

682.6

250.72

443.81

Billing Multiple Debridements

CPT® guidelines do not restrict the number of times debridement codes can be reported for a course of treatment so 11040-11044 may be used more than one time in a single patient encounter for debridement of multiple sites (wounds). The ap-propriate code is selected for each site depending on the type of debridement performed, and modifier 59 Distinct procedural service is appended to the secondary (and tertiary, if applicable) code.
When billing multiple site/wound debridements, document each site/wound. Medicare only pays for up to five debridements before requiring medical records to be submitted to substantiate medical necessity for each.
For example: A 40-year-old male who was riding a mountain bike falls and suffers multiple wounds on his forehead, arms, and legs, with a lot of foreign material in the wounds. He presents to the ED and after assessment the ED physician performs excisional debridement of the wounds to prevent infection. There is a 5 cm open wound to the right hip/thigh area that goes to the muscle, a 4 cm open wound to the left calf that goes to the muscle, a 4 cm open wound to the right bicep, and a 2 cm wound to the forehead. The ED physician debrides the right bicep and the forehead wound, and then oversees a plastics fellow debride the hip and the calf.
Code as follows:

99284-25

890.1 Open wound of hip and thigh, complicated

E826.1 Pedal cycle accident injuring pedal cyclist

E849.4 Place for recreation and sport

11043-GC Teaching physician was present during the key portion of the service and was immediately available during other parts of the service

890.1

E826.1

E849.4

11043-59-GC Distinct procedural service

891.1 Open wound of knee, leg [except thigh], and ankle, complicated

E826.1

E849.4

11042-59

880.13 Open wound of shoulder and upper arm, complicated, upper arm

E826.1

E849.4

11040-59

873.52 Other open wound of forehead, complicated

E826.1

E849.4

Watch for Global Periods

Global periods for debridements vary according to depth:

• The global period for 11040, 11041, and 11042 is zero.
• The global period for 11043 and 11044 is 10 days—meaning that all the pre-service, intra-service, and post-service work (up to 10 days for 11043-44) and cost to provide the service are included in the code.

For example: A 25-year-old female trips and falls on the street and is treated in the ED five days prior. The ED physician per-forms a partial thickness debridement of her cheek (complicated), packs the wound, prescribes a course of antibiotics, dis-charges her home, and tells her to return in five days for a recheck. At the time of service, coding is:

99283-25 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and medical decision making of moderate complexity

873.51 Other open wound of cheek, complicated

E885.9 Slip and fall, unspecified

E849.5 Place of occurrence, street

11040

873.51

E885.9

E849.5

The patient returns to the ED for follow-up care. After an assessment on the fifth day, the ED physician cleans the wound, dresses it again, and continues the patient’s current course of antibiotics. Because 11040 has a global period of zero, the visit may be reported with:

99281 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components; A problem focused history; A problem focused evaluation; and Straightforward medical decision making

873.51

V58.31 Encounter for change or removal of surgical wound dressing

E885.9

E849.5

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