Optimize Payment for Wound Care By Linking CPT and ICD-9

The key to optimizing reimbursement for diagnosing and treating infectious wounds (11000-11044) is to ensure the proper linkage between the CPT and ICD-9 codes submitted for billing, says Judy Richardson, RN, MSA, senior consultant with the Wilmington, N.C.-based coding and compliance firm Hill & Associates.

Patients often present with more than one condition so, several diagnostic codes are used, Richardson notes. When wound care is provided, the coder must then link the actual diagnostic code to the procedure code. For example, Richardson says, suppose the infectious disease (ID) physician sees a patient with multiple morbidities, such as diabetes (250.0x), arthritis (716.9x) and hypertension (401.9). Then, during the visit, the ID physician provides extensive wound care on a leg ulcer (707.1) that is a direct result of the patients diabetes. The codes submitted to the payer must link the diagnostic code for diabetes to the wound-care procedure code. If the codes do not match, and the arthritis code is used instead, the claim most likely will be denied, causing a delay in reimbursement while an appeal is made, Richardson says.

While there may be some differences among payers in terms of fee schedules and reporting requirements for lengthy and/or difficult procedures, Richardson says, most handle wound treatment in the same way: The ID physicians documentation must support the levels and treatments that have been submitted for reimbursement. And should there be any discrepancies between services provided and those billed, these most likely will result in denial of payment and time lost refiling and appealing the denial.

Wound Care Codes

The most commonly used codes for wound care fall in the Excision-Debridement range: 11000-11044, with 11040-11044 being the most used. These codes should be used to describe the actual treatment provided by the physician rendering the wound care. Coders and providers should be aware of the 11010-11012 codes that more accurately represent extensive debridement procedures, Richardson says. It is important to ensure that the provider is billing for services on the proper level and, therefore, being reimbursed appropriately, she explains.

Coders and providers should be aware of any modifiers that might need to be used, Richardson adds. Extensive debridement procedures can be performed multiple times during a session, depending on circumstances, she notes. In addition, she says, some procedures that require more than one debridement on the same wound area may be staged. In each of these circumstances, the correct codes depend on the particular service performed.

You can use these modifier codes for this activity:
-51 (multiple procedures), -58 (staged or related procedure or service by the same physician during the postoperative period) and -78 (return to the operating room for a related procedure during the postoperative period), Richardson says. Procedures [...]

- Published on 2000-05-01