ED Coding and Reimbursement Alert

Multiple lesions, multiple codes? Maybe.

When your ED physician performs debridements, be sure to note whether the service was partial- or full-thickness, or you'll overcode the encounter.

Follow this FAQ to submit spot-on debridement claims each time.

1. What Is a Partial Thickness Debridement?

The most common ED presentation for debridement involves partial-thickness debridement, which you'd code with 11040 (Debridement; skin, partial thickness). "A partial-thickness debridement includes the epidermis and part of the dermis, but some dermal cells are left," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPCP, COBGC, CCC, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program. The physician typically performs these procedures using a scalpel or scissors, depending on the situation, she says.

(Remember that a wound requiring 11040 is mostly dermal; debridements that extend past the dermis may be a candidates for a higher-level code.)

Example: A patient presents with a minor laceration on her right knee that occurred when she was playing ultimate Frisbee several days ago. The wound is now crusted with devitalized tissue. During a level-two ED E/M service, the non physician practitioner (NPP) performs a partial-thickness debridement, removing the scabs and devitalized tissue from the edges of the wound; he then applies bandages, provides antibiotics, and sends the patient home.

For this scenario, report the following:

• 11040 for the debridement
• 99282 (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 low complexity ...) for the E/M service
• modifier 25 (Significant, separately identifiable evaluation and management service on the by the same physician on the same day of the procedure or other service) appended to 99282 to show that the debridement and E/M were separate services
• 891.0 (Open wound of knee, leg [except thigh], and ankle; without mention of complication) appended to 99282 and 11040 to represent the patient's injury
• E008.3 (Activities involving other specified sports and athletics; Frisbee) appended to 99282 and 11040 to represent the cause of the patient's injury.

2. What Is a Full-Thickness Debridement?

Wounds requiring full-thickness debridement include removal of both the epidermal and dermal layers of the skin. "There are also debridement procedures involving subcutaneous tissues or, depending on the location, muscle fascia or even bone," Bucknam explains.

As with 11040 services, the provider will typically use a scalpel or scissors for a fullthickness debridement, depending on the situation.

Example: A patient presents with a chronic deep wound on his right shoulder that shows signs of infection. The patient reports that the injury occurred during a backcountry backpacking trip. The ED physician performs a level-three E/M service, during which he notes necrotic and inflamed tissue. Final diagnosis is: "degen. Skin disorder." The ED physician then uses scissors and a scalpel to remove all of the necrotic tissue from the wound, including a full-thickness debridement of the patient's epidermis and dermis.

For this scenario, report the following:

• 11041 (... skin, full thickness) for the debridement
• 99283 (an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the ED E/M
• Modifier 25 appended to 99283 and 11041 to show that the E/M and debridement were separate services
• 880.10 (Open wound of shoulder and upper arm; complicated; shoulder region) appended to 11041 and 99283 to represent the patient's open wound
• 709.3 (Degenerative skin disorders) appended to 11041 and 99283 to represent the patient's skin disorder.

3. What Documentation Do I Need?

Consider documentation detailing the debridement an important part of each 11040-11041 claim, says John Bishop, PA-C, CPC, with Bishop and Associates in Tampa, Fla. Coders should encourage physicians to describe the specific layers they debrided, and the type of tissue removed. "If only the area of the opening is documented, there is not enough documentation to support the debridement," warns Bishop.

How Should I Code Multiple Debridements?

This can get tricky; there is often a fine line between singleand multiple-code debridement services, even when it appears the ED provider debrided "multiple" injuries.

In short: If the physician performs debridement on multiple wounds for the same patient during the same session, make sure you code each removal separately. But ... For "contiguous sites," you should code only the deepest level of debridement, Bucknam explains. This question may be particularly pressing for a patient who presents after trauma, as the physician might debride the same wound to different levels.

Check out these two examples of "multiple" debridements with different coding outcomes:

Example 1: A patient who suffered several injuries during a motor vehicle accident (MVA) is brought to the ED via ambulance. Operative notes indicate that the physician performed partial-thickness and full-thickness debridement on the same chest wound.

In this example, you'd report 11041 for the debridement.

Example 2: A patient who suffered several injuries during a MVA is brought to the ED via ambulance. Operative notes indicate that the physician performed partial-thickness debridement on the patient's upper right chest wall, as well as full-thickness debridement on the patient's left leg. In this example, you'd report the following for the debridement:

• 11041 for the full-thickness debridement
• 11040 for the partial thickness debridement
• Modifier 59 (Distinct procedural service) may also be required on 11040 to show that the debridements were separate services.