Pediatric Coding Alert

Know what to do when the debridement code is in column one.

Typically when the calendar turns to the end of the year, the Correct Coding Initiative (CCI) edits are rather light—but not this year. CCI version 22.3, which went into effect on Oct. 1, will impact pediatricians who perform debridement procedures.

Tip:  If your pediatrician ever performs debridement with any other procedure, you should check the CCI lists. Most of the procedural codes that you use in pediatrics are included in this version of the edits.

Pay Attention to These Edits Involving Debridement Procedures

According to CCI version 22.3, dozens of pediatric procedure codes are considered a Column 1 code with each of the following debridement procedures:

• 11000 (Debridement of extensive eczematous or infected skin; up to 10% of body surface)
• 11004 (Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum)
• 11005 (…abdominal wall, with or without fascial closure)
• 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less)
• 11043 (Debridement, muscle and/or fascia [includes epidermis, dermis, and subcutaneous tissue, if performed]; first 20 sq cm or less)
• 11044 (Debridement, bone [includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed]; first 20 sq cm or less)
• 97597 (Debridement [e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application[s], wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound[s] surface area; first 20 sq cm or less)
• 97602 (Removal of devitalized tissue from wound[s], non-selective debridement, without anesthesia [e.g., wet-to-moist dressings, enzymatic, abrasion], including topical application[s], wound assessment, and instruc­tion[s] for ongoing care, per session).

In addition to the above-mentioned codes, the list also includes +11001, +11045, +11046, +11047 and +97598, which are add-on codes to 11000, 11042, 11043, 11044and 97597, respectively.

Debridement bundles into these services: The majority of the above debridement codes are column two codes for common pediatric procedures, including integumentary codes (10040-17250), several musculoskeletal codes, and removal procedural codes of the external ear (69200-69210).

“These edits are generally consistent with Current Procedural Terminology (CPT®) guidance regarding reporting of debridement,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Debridement is generally understood to be part of a more extensive procedure when that procedure is reported. For instance, CPT®  guidelines preceding the integumentary repair codes (12001-13160) indicate that debridement is part of such services. Those guidelines specifically state, ‘Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure,’” Moore adds.

Modifier indicator: Each of these above-mentioned edit pairs carries a modifier indicator of “1,” meaning that you might be able to report both codes in an edit pair if you have sufficient documentation to support separate coding. If your records support separating the bundles, append a modifier such as 59 (Distinct procedural service) to the column 2 code.

Understand When Edits are Reversed

Although most of the new bundles involving debridement make the debridement code in the column 2 service, there are occasions where you’ll find the debridement code in column one of the edits instead. For example, the following services are now bundled into debridement:

• Body and upper extremity cast application codes (29000-29086)
• Body and upper extremity splint application codes (29105-29131)
• Body and upper extremity strapping codes (29200-29280)
• Lower extremity cast application codes (29305-29450)
• Lower extremity splint application codes (29505-29515)
• Lower extremity strapping codes (29520-29584).

Modifier indicator: As with the debridement codes in column two mentioned earlier, these edits with cast, splint and strapping codes also carry the modifier indicator ‘1.’ You can report these column two codes separately if you append a suitable modifier such as 59 with these codes. Since the debridement codes are column one codes for these edit bundles, you will report these codes without the use of a modifier.

Example: Your pediatrician treats a 13-year-old male patient who presents to your practice with injuries sustained in a skateboarding incident. The evaluation reveals that the patient has a fractured left elbow and multiple injuries on the left upper arm and left knee. Your clinician decides to place a long arm splint to stabilize the fractured elbow until an orthopedist can treat it later. Since the wounds had gravel in them, your clinician then debrides the wounds on the arm and knee. This debridement mostly involves the skin and includes some portion of the subcutaneous tissues. The total area is less than 20 square centimeters. Your pediatrician then places a topical antibiotic and dresses the wounds.

What to report:  In this scenario, your clinician performed placement of the long arm splint and debridement of wounds of the arm and the knee. Therefore, you’ll report the following codes:

• 11042 to report the wound debridement
• 29105 (Application of long arm splint [shoulder to hand]) with modifier 59 appended to indicate this was distinct from the debridement, which involved the knee as well as the arm
• the appropriate level E/M code with modifier 25»» » (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to indicate that the physician did the work of evaluation and management above and beyond that which is usually included in the procedures
• S41.122A (Laceration with foreign body of left upper arm, initial encounter) and S81.022A (Laceration with foreign body, left knee, initial encounter) appended to 11042 to represent the patient’s injuries
• S42.402A (Unspecified fracture of lower end of left humerus, initial encounter for closed fracture) appended to 29105 to represent the patient’s fracture
• Y93.51 (Activity, roller skating [inline] and skateboarding) appended to 11042, 29105, and the E/M to represent the cause of the patient’s injuries.

Resource: If you have not already reviewed the latest CCI edits, you can find them on the CMS web site at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/.