Podiatry Coding & Billing Alert

Question: Upon examination, the podiatrist notes that the patient has a right midfoot non-pressure ulcer with necrosis of muscle. The podiatrist documents a diagnosis of a midfoot non-pressure ulcer. The podiatrist preps and anesthetizes the patient and performs prolonged cleansing of his ulcer. The podiatrist then uses forceps and scissors to remove the damaged tissues and necrotic material from the skin and muscle layer, which involves skin, subcutaneous tissue, fascia, and muscle. The provider excises tissue from the wound until he sees healthy bleeding on the skin’s edges. The provider then controls the bleeding, applies an antibiotic, and dresses the wound. The size of the wound is 4.0 cm x 3.5 cm. Which ICD-10 and CPT^® codes should we report for this encounter?

Hawaii Subscriber

Answer: You should report L97.413 (Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle) for the ICD-10 code. The necrosis indicates that there is likely inadequate perfusion to the wound — a vascular issue.

For the CPT^®  code, you would report 11043 (Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less).