Can someone tell me... is "excisional debridement, full thickness" enough documentation to code 11042? I am thinking that if the depth of the debridement (or depth of ulcer) is not documented, it will have to be coded 97597. Does that sound right?
From CMS.gov
Documentation Requirements
1. The medical record must clearly show that the criteria listed in LCD GSURG-051 under “Indications and Limitation of Coverage and/or Medical Necessity” have been met.
2. There must be a documented plan of care with documented goals and documented provider follow-up present in the patient's medical record. Wound healing must be a medically reasonable expectation based on the clinical circumstances documented.
3. Documentation of the progress of the wound's response to treatment must be made for each service billed. At a minimum this must include current wound size, wound depth, presence and extent of or absence of obvious signs of infection, presence and extent of or absence of necrotic, devitalized or non-viable tissue, or other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown.
4. When debridements are performed, the debridement procedure notes must document tissue removal (i.e. skin, full or partial thickness; subcutaneous tissue; muscle; and/or bone), the method used to debride (i.e., hydrostatic versus sharp versus abrasion methods), and the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement.
5. When, the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
Effective Date:
*01/01/2011
Published/Website: