Code Wound Care Correctly With These Tips
Payer auditors are increasing their scrutiny of wound care reporting. Gena Cornett, CPC, CPB, CPCO, CRCR, RCMS, CPB-1, offered some tips for coders to gain confidence in following guidelines for coding wound care in her presentation “From Wounds to Wins: Expert Tips for Accurate Coding” at AAPC’s HEALTHCON Regional 2025. Here’s what you need to know about compliance and documentation when reporting wound care procedures. Follow LCDs Closely Documentation is always crucial for patient care and reimbursement, but accurate documentation and coding are especially important for wound care because of compliance, financial impact, and patient outcomes. “Wound care is a high target for compliance audits,” Cornett said, noting that many providers/organizations have gone through targeted probe and educate (TPE) audits for debridement, cellular tissue product use, and hyperbaric oxygen therapy. Auditors are paying close attention to Medicare Administrative Contractor (MAC) local coverage determinations (LCDs) and checking whether providers documented all the elements to meet medical necessity in the LCDs. The LCDs pertinent to wound care contain a lot of guidelines, and payer auditors are looking at incorrect billing. “If they find that your doctor or provider has a lot of errors, they’re going to come back again and look at it. We see some organizations and providers who go through two or three rounds of TPEs before they pass,” she said. She encouraged providers to take advantage of the education sessions MACs provide, especially because providers/organizations who become a target of TPE face sizable financial impact. Medicare is looking at documentation to figure out what providers are using and to determine reimbursement going forward. But perhaps most importantly, accurate documentation for wound care helps patients get the services and durable medical equipment (DME) they need, like patients who need hyperbaric oxygen after debridement. “If we haven’t accurately captured that they’ve met a period of conservative wound care, then they may not get preauthorized for that service they need,” she said. Beware: Cornett warned that the Centers for Medicare & Medicaid Services (CMS) is continuing to evaluate coverage for skin care substitutes, so make sure you’re continually checking which products will be reimbursed. Understand Debridement Basics Debridement falls into two main categories: surgical, which entails the removal of deeper layers of tissue, fat, muscle, fascia, and bone; and active wound care, which may also be referred to as open or selective wound debridement. When coding wound debridement, you’re going to look at the depth and choose the code that represents the deepest level of tissue removed and the surface area of the debridement. Surface area calculations have changed as more providers have started using the ellipse formula, which uses pi, rather than just length times width. Cornett said the ellipse calculation can be more accurate, as wounds present as many shapes. Check your electronic medical record (EMR) system to make sure you know what formula it uses, so you can take that into account as you’re selecting codes. Use These Tips to Capture Debridement Wound debridement code is not selected based on the instrument used, Cornett said. Code based on the actual area of the wound debrided, even if the physician didn’t debride the entire wound surface — which sometimes happens if they see good granulation, as they’ll choose to remove only the necrotic tissue, she explained. So make sure the actual debridement is captured and not just the size of the wound. Also, know which parts of procedures are bundled and which are separate. For example, some providers use silver nitrate to stop bleeding, but you can bill 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)) only if the provider uses it to remove hypergranulation tissue. “We can’t charge both. We’re just going to charge for the debridement,” she warned. Be familiar with the difference in surgical debridement and burn debridement, because each has their own set of codes. The burn-specific codes often encompass dressing or debridement, so even if the patient is receiving a dressing change, coders may be able to report the following burn debridement codes: “That’s also for full- or partial-thickness wounds. So sometimes you’ll say, well, it’s a third-degree wound, we’re still going to use those codes if we’re doing a dressing or debridement, if it’s a burn,” she said. When reporting multiple wounds, add the depths together, Cornett said. “So if we have two wounds on the calf and we debrided both of them to the subcutaneous level, we’re going to add that surface area together to get our appropriate code. If we debrided them to different levels, then we’re going to pick two codes and use the appropriate modifier.” MAC Noridian offers a list of modifiers, some of which are directly applicable to wound care coding, including modifiers A1 (Dressing for one wound) to A9 (Dressing for nine or more wounds). Keep in mind that you may need to utilize add-on codes in addition to the initial procedure code, and that you may have to navigate National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs). “If you are billing for the physician office, either for the facility billing or in the private office, you can appeal those MUE denials with your documentation proving that the physician actually debrided this huge ulcer and there was medical necessity for it,” she said. However, if you’re billing under the Hospital Outpatient Prospective Payment System (OPPS), many of those add-on codes are bundled in and you’re not going to get reimbursed for them, Cornett said. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
