Dermatology Coding Alert

Published on Tue Jun 08, 2004 PDF

Maximize 11040-11044 pay with modifier -51

In most cases, your practice won't report debridement separate from wound repair codes. But when exceptions arise, follow these three tips to choose the appropriate wound repair code.

If you're considering reporting debridement separate from a wound closure, make sure your physician's notes clearly document that the wound was contaminated and required saline or other substances or instrumentation to cleanse and debride the wound, says Linda Martien, CPC, CPC-H, coding consultant at National Healthcare Review Inc. in Woodland Hills, Calif.

Don't miss: If you report a debridement code with your wound closure codes, append modifier -59 (Distinct procedural service) to the debridement code. This informs the payer that you recognize that debridement is generally bundled into wound repair, but that clinical circumstances required the physician to perform debridement as a separate service.

CPT specifies that you may also report debridement codes independently of repair codes when the physician removes large amounts of devitalized or contaminated tissue or when the physician performs debridement without immediate primary repair of a wound.

The physician may clean debris from the wound without repairing the wound because it was either not deep enough to require repair or the physician delayed the repair due to an extenuating circumstance.

For example: The physician may not have enough time to repair the wound at that time or the patient may present with a more significant skin condition that requires medical attention first. In such a case, you can bill debridement for full, separate payment without a wound repair code. For instance, a patient presents with a basal cell carcinoma on the bridge of her nose and upon excising the lesion, measuring 0.3cm with margins (11640, Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less). He may also need to debride the bone underneath for any potentially invasive carcinoma (11040, Debridement; skin, partial thickness).

Documentation example: Using the above-mentioned scenario, the documentation might read, "Patient presented with basal cell carcinoma on the tip of her nose. The physician first anesthetized the area with Lidocaine and 1 percent epenephrin. The lesion with margins measuring 0.3 cm was excised with further debridement to assure clean margin throughout. The physician then applied antibiotic ointment and light dressing." You should report this scenario using codes 11640 and 11040 also with modifier -51 (Multiple procedures). The order is important as you will read in the following.

Although physicians most commonly clean a wound immediately before they repair a wound, you wouldn't report a debridement code separately. Don't miss: The debridement procedure may also necessitate a repair procedure that will affect your billing report.

If the physician performs a simple repair with minimal amounts of debridement, for instance, you should only report a simple repair code (12001-12021). If that same wound needs extensive cleaning or removal of particulate matter, you may instead report an intermediate repair code (12031-12057).

Money opportunity: There is a significant difference in payment between simple and intermediate repair codes. Reporting code 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) will reimburse you approximately $154 whereas 12031 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) may pay $175. The difference in reimbursement reflects the difference in the repair, states Marie West, CCS-P, CMSCS, CCP, coding specialist at Medical Data Services Ltd. in Edmond, Okla. Specifically, the intermediate repair involves more time, effort and supplies than the simple repair and therefore is reimbursed at a higher rate.

Simple repairs require a simple one-layer closure involving the epidermis, dermis or subcutaneous tissues without significant involvement of deeper structures, according to CPT. Intermediate repair involves layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, addition to the skin (epidermal and dermal) closure. Therefore, if the physician performs a one-layer closure, you should report the repair with the appropriate simple repair code (12001-12021), West says. If the physician performed a multiple layer closure, however, you should report the repair with the appropriate intermediate repair code (12031-12057), she advises.