Appeal for 11042 vs 97597

Messages
13
Location
Bettendorf, IA
Best answers
0
I bill for a wound care clinic and had submitted some redeterminations to Medicare for large debridements that they say were billed with too many units (eg. 11042, 11045 x30 units for a debridement of 600 sq cm) The response I got back is unfavorable stating that 97597, 97598 are the proper codes for recurrent debridement services. But after doing some research, it seems to me that 97597, 97598 is only for debridement of the epidermis/dermis and 11042, 11045 is for the subcutaneous tissue (which is the depth the dr debrided). Before I go to the next level with appeals I wanted to see if anyone out there had any knowledge to share with me about this. Thanks!
 

smsmith

Networker
Messages
33
Best answers
0
I also bill for physicians that work in a wound center. I have sent in multiple appeal letter to our Medicare carrier for the 11045 that they deny above 4 units. I had a few come back unfavorable, but most came back favorable and the additional payment was made. As long as the documentation in the progress note and procedure note supports the level and size of debridement, you should have enough to challenge it. The reimbursement is so much more for the excisional vs the selective.
 

smsmith

Networker
Messages
33
Best answers
0
I came upon a Medicare Learning Network issue ICN 006973 from Nov 2011 that talks about Medicare Claim Review Programs, and MUE's specifically. It states you can bill the code that is in excess of the MUE, such as 11045, using a single line item for each one and billing them with -76 modifier. This was the first I had heard of doing this. This might work ok if you have a unit total of 10 or so on the 11045, but on larger ones...I just don't know.
 
Top