Orthopedic Coding Alert

Remember to pay attention to NCCI on multiple debridements.

Patients that need emergency orthopedic surgery are most often people with broken legs, torn shoulder muscles, twisted ankles, etc. There are times, however, when a patient requires also requires soft-tissue treatments to help alleviate their conditions.

Often, these scenarios involve extensive debridement. Check out these emergency scenarios that involve debridement, and see if you can code them correctly:

Scenario 1: A patient meets the orthopedist at the hospital after a cycling accident, which resulted in deep cuts on his left leg. The orthopedist documents that the wounds measure 30 sq. cm and that they had gravel in them that needed to be removed. You report 11042 with +11045 and 10120 together. Is this the right coding selection? And if so, do you need a modifier?

Answer 1: Your classification of the wound as “deep,” and your provider’s documentation of the total area of the wounds, suggests that you should be able to go ahead and report 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) with +11045 (...  each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)) for the service rather than, say, 97597 (Debridement ... first 20 sq cm or less) and +97598 (... each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)).

Coding alert: “If you have wounds  of the same depth, i.e. subcutaneous tissue, although on different anatomical sites, you would add the surface area together and code based on the total surface area; no modifier is needed,” reminds Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

Also, “remember if the entire wound surface is debrided, then the measurement of the wound is taken after the debridement procedure. If only a portion of the wound is debrided, only report the measurement of the area of the wound that was debrided,” Brink continues.

Make sure that your provider’s notes indicate that the procedure involved going deeper than the patient’s epidermis or dermis and into the subcutaneous tissue. Although CPT® instructs to report the depth using the deepest level of tissue removed for a single wound, for multiple wounds, you should also make sure that the wounds were all debrided at the same depth, as CPT® guidelines require you to “sum the surface area of those wounds that were at the same depth.”

Reporting 11042 and +11045 with 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) is trickier. The two services are distinct and not bundled per National Correct Coding Initiative (NCCI) edits, but debridement often involves the removal of foreign bodies as well as dead or damaged tissue from a wound. So, when you report 11042, you are essentially saying that your physician also performed the service described by 10120.

However, if your physician’s notes indicate that the debridement occurred in one anatomical area, say the knee, and the removal in another, say the shin, then you would have a case for documenting 11042 and +11045 with 10120. To be safe, you could append modifier 59 (Distinct procedural service) to either 11042 or 10120. This would not only alert your payer that the two services were separate but might also facilitate swifter processing of the claim.

Coding alert: To substantiate performing 11042 and +11045, the medical record documentation must state the level of debridement the provider performed. “Remember, if it is not documented, it was not performed,” says Brink.

Does Debridement Fit into This Scenario?

Scenario: A patient presents to the emergency department (ED) after cutting the tip of his finger off while removing the grass catching attachment from his lawnmower; the ED physician sends the patient to the orthopedic surgeon. The ED physician’s notes read “13:51 Hemostasis: Moderate amount of left phalanx of 3rd and 4th digits.” Your surgeon cauterizes both digital arteries of the fourth digit and coats with gel foam, which stops the bleeding. Can you report debridement for this service?

Answer: In some cases, you can, but it will depend on the documentation.

Typically, this kind of ED presentation of a partially amputated finger includes stabilizing the injury, extensive undermining, and debridement before suturing the remaining skin over the exposed bone. This scenario would commonly be reported using a complex laceration repair code such as 13131 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm).

In cases where the exposed bone is too long for such a repair, a rongeur is often used to snip the bone back far enough to leave a suitable skin flap before the repair is performed. Depending on the documentation, you might consider reporting that extra work with code 11044 (Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less). Be advised that there are NCCI edits between 11044 and the laceration repair codes.

So, depending on the nature of the bone debridement, only the complex repair code should be reported (remember, since the ED physician admitted the patient, they’ll code for the E/M). There is also a code for partial finger amputation, 26951 (Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure), which you might use depending on the documentation.