Wiki Large wound debridements - 11043, 11046

[LISALININGER]

I am trying to bill for debridement to muscle for a wound that measures 98 sq cm. I billed 11043 and that code paid correctly. I then billed 11046 x 4 for the remaining 78 sq cm. Medicare denied stating the x 4 exceeds the frequency allowed for this CPT code. I cannot find any documentation that states what that frequency limit is. I called my MAC and was told the maximum number is "unpublished by CMS so she cannot release that information to me". How am I supposed to use this code to bill correctly for the wound size that was debrided?

 

[espressoguy]

I am trying to bill for debridement to muscle for a wound that measures 98 sq cm. I billed 11043 and that code paid correctly. I then billed 11046 x 4 for the remaining 78 sq cm. Medicare denied stating the x 4 exceeds the frequency allowed for this CPT code. I cannot find any documentation that states what that frequency limit is. I called my MAC and was told the maximum number is "unpublished by CMS so she cannot release that information to me". How am I supposed to use this code to bill correctly for the wound size that was debrided?

I have seen this in writing although I can't tell you where, perhaps an LCD? At any rate, Medicare will pay a maximum of 4 units (11043, 11046x3). Assuming the documentation supports the larger debridement, they more than likely will pay on appeal.

Be careful though. We appealed a large debridement denial and not only was the appeal denied, but Medicare wanted their money back for the entire claim

 

[LISALININGER]

Thanks for the info!