Debridement and Unna/Compression CPTs for different wound conditions

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I'm hoping you all can help me find some documentation that I've lost. My research found that if I have a Venous Insufficiency ulcer, I can code Debridement AND Unna/Compression with a -59 modifier because the Debridement is for the ulcer and the Unna is for the separation condition for the Venous Insufficiency. I cannot find where I saw that! I am putting materials together for an audit and really need to find where I saw that. Thanks in advance - Laura
 

thomas7331

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I never heard anything like this when I was doing wound care coding. Per the CPT instructions for modifier 59 usage, "documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual." The fact that the Unna boot is related to a different 'condition' does not meet these criteria. Unna boots are routinely used after ulcer debridement and unless it was applied to a different extremity, I believe the modifier use would be inappropriate unbundling. If you find do a credible source that says otherwise, please share it with us.
 
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Current CPT Assistant?

I did find one of my documents that seems to support the venous compression with 97597. I also haven't had any billing denials in 2 years on this with venous ulcers. Does anyone know if there is a correction to this CPT Assistant from May 2011?

Debridement

CPT Assistant, May 2011 Page: 3-5, 11 Category:

Related Information

Question:



A chronic ulcer of the calf measures 10 cm x 11 cm (110 sq cm). Approximately 30% (33 sq cm) of the ulcer requires debridement of slough and eschar at the dermis (code 97597). The physician manages the entire wound, debrides 33 sq cm, dresses the entire wound appropriately, and applies a multilayer of high-compression bandage system to the entire wound. How is this reported?



Answer:



Because the depth of the debridement was to the level of the dermis and only 33 sq cm of the wound was debrided, the procedure is reported using the two debridement codes: code 97597, Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, 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, and add-on code 97598 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, 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; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure).



In this case, codes 97597 and 97598 are each reported only once. Code 97597 for the first 20 sq cm and code 97598 for the next 13 sq cm. The application of the wound dressing is not separately reported. However, the application of the multilayer high-compression bandage system is reported using code 29581, Application of multi-layer venous wound compression system, below knee.
 
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thomas7331

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I do see that this is addressed in the CMS NCCI Manual, in Chapter 4, Section G, paragraph 3: "Debridement CPT codes (e.g., 11042-11047, 97597) and grafting CPT codes (e.g., 15040-15776) should not be reported with a casting/splinting/strapping CPT code (e.g., 29445, 29580, 29581) for the same anatomic area." This would suggest that neither an Unna Boot nor a compression dressing would be separately reportable with a modifier 59 if used at the same location as the debridement. Regarding, the CPT assistant scenario above, I'd note that CPT guidelines do sometimes differ from NCCI - CPT sometimes instruct to report a code in cases where NCCI bundles it. Unbundling it with a modifier 59 just because CPT says to report it would still be inappropriate if the payer policy follows the NCCI in formulating it's reimbursement rates.
 
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TCC exception

Thank you, Thomas. I also should have been more clear about the casting side that I was talking about Total Contact Casting, 29445. This is allowed, see this CC:


Contact cast application in wound care center

CPT Assistant, September 2011 Page: 11 Category: Frequently Asked Questions




Application of Contact Cast in Wound Care Center



Question:



Our outpatient wound care centers are performing total contact casting. If the patient presents to the wound care center to have a contact cast replaced, what is the correct CPT code to report? Also, if the patient has a wound debridement reported with CPT code 11042, and a total contact cast is applied to the same extremity, is it appropriate to report both the debridement and the cast application?



Answer:



CPT code 29445, Application of rigid total contact leg cast, is the appropriate code to report for the total contact cast application. A Total Contact Cast (TCC) is used to reduce the pressure and/or shear forces on a lower extremity wound, typically on the plantar surface. The cast improves the ability of the wound to heal. If a wound debridement is performed (codes 11042-11047, 97597-97598), any primary or secondary dressing materials used to cover the wound would be included in the debridement and would not be separately reported. However, a TCC is not considered a wound dressing and is not included in the debridement procedure. Therefore, the cast application should be coded in addition to the code for the appropriate level of debridement, if performed. A TCC application applied on a visit when wound debridement is not performed should be reported with code 29445 (some payers may require that the appropriate site modifier RT or LT be appended).
 

thomas7331

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I hear what you're saying, and you can certainly 'report' those procedures, but the issue you're going to run into with this is not that if you follow the CPT or CPT assistant instructions and bill the TCC or the Unna boot with a debridement is that it's going to be denied by the payers that follow NCCI unless you use a modifier. If you unbundle it with a modifier but the two procedures are on the same extremity or same location, then your modifier is likely not going to be supported by documentation and will not hold up in an audit. CPT assistant is telling you that these codes can be reported together but it's not telling you it's appropriate to append the modifier to get payment. NCCI is a reimbursement policy, not a coding policy. Payers that follow NCCI have already calculated the cost of the TCC or Unna boot into their rates for the debridement and they will consider it an overpayment if your modifier is not supported.

There are a number of other instances similar to this where NCCI conflicts with CPT instructions (billing closures with lesion excisions smaller than 0.5 cm, and billing surgical microscopy with spinal surgeries are a couple of other examples). It's important to remember that 'reporting' and 'unbundling' are two different things. Unbundling is inappropriately bypassing a reimbursement rule with a modifier that is not supported. The CPT guidelines for reporting a code unfortunately don't give coders the license to also use a modifier inappropriately when a payer denies that code based on their fee structure.
 

mjstack

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TCC with HBO same day

Hello, In the line of discussion of bandaging with another procedure; I have been told by the facility nurse we cannot bill for total contact cast done on the same day as the patients HBO treatment (they removed it before and replaced after) since its a "cast" not "bandages" can I not bill for it in addition to the HBO service? thank you any advice or direction//mj
 
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