weekly wound debridment

madcomic2000

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I queried our medicare contractor (WPS) for information regarding the use of 11042 for weekly wound debridements - typically for our diabetic and decubitus ulcer patients. They sent me the following information...

"To help me answer your questions, I consulted with Medicare Policy staff for clarification. WPS Medicare Medical policy staff indicated that the CPT coding system does not recognize “serial debridement.” CPT codes 11042 and 11043 are normally billed once. Following the use of 11042/11043, follow up CPT codes 97597 and 97598 are appropriate. This decision was made after the WPS Medicare Carrier Medical Director (CMD) reviewed claims and documentation such as medical records and operative reports for over a period of two years."

They basically state 11042 for subcutaneous debridement should be billed once, then we are to use 97597-97598 codes for weekly treatment thereafter. We disagree with this assessment as does our physicians as they are performing work that exceeds those codes. Do you have any advice on where to start appealing this decision?? It's not specifically in their LCD, but in the billing guidelines link at the end of policy.

Thanks,
Melissa
 

cmartin

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NGSMedicare.com LCD= L27373. It's for Indiana & others, & they cite carriers for New York, NJ, Conn, &Delaware as sources in developing their policy. They have specific dxs & some other hoops, but they mention a case that MAY exceed med necessity if diabetic foot ulcer treated >1 every 7 days for >3 mos. Here's a general passage re numbers:

CPT codes 11042-11047 should be used for debridement of relatively localized areas depending upon the involvement of contiguous underlying structures. These codes are appropriate for treatment of skin ulcers, circumscribed dermal infections, conditions affecting contiguous deeper structures, and debridement of deep-seated debris from any number of injury types.

The number of debridement services required is variable and depends on numerous intrinsic and extrinsic factors. Debridement services are covered provided all significant relevant comorbid conditions are addressed that could interfere with optimal wound healing.
---
It is clear in numerous areas of the policy that they don't consider 11042 to be a one-time procedure. Several mentions of 11043 & 11044 needing real good documentation if used >5 times.
It's a long policy, but i think you could get good ammo from it for your battle w/WPS!
 

espressoguy

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My primary duty is to code for our hospital's Wound Clinic. I can't point you towards any CMS documentation to support your case, but I will say, that we have no problems getting any subsequent 11042-47's paid. However, this is not to say our wound care docs perform subcutaneous debridement every time they see a patient. They perform far more 97597's.

As you may know, last year debridement codes changed with the elimination of 11040-41. Now the determining factor in which code to use is wound size and depth. Debridement that doesn't go down to subcutaneous tissue is coded as 97597/98. As long as the documentation clearly states that the debridement was "down to and including subcutaneous tissue," I can't see why there would be a problem coding 11042. On the other hand, I don't recall any of my docs doing subcutaneous (or deeper) debridement more than a few times over a course of treatment.
 

madcomic2000

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That's part of the issue at hand. The documentation does state the tissue is debrided down thru the subq and the photos we take clearly show how deep into the tissue we are. Even with this information, WPS has stated, "rare exceptions will a provider bill recurrent debridements > 1 time". I have my doctors writing letters that I can send back to the medical director to attempt to override this decision as it's off base, in my opinion.
 

cyn77

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Wound debridment

I also am confused on the debridment code 11042 vs using 97597.doc sees pt for injury to back of leg. There was a hematoma on back of leg behind. They applied pressure and it ruptured, therefore the area was debrided and removal of that flap also removal of eschar above the flap. Now do we code 99213 plus 11042 or just 97597.help?
Thanks, cyn77
 

lalalindy

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Grafton, WI
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Re: Weekly Wound Debridement

Melissa,

What was the outcome of your letter writing? I agree with you that the CPT definitions for 11042 and add-on code 11045 are different from the way WPS is interpreting them. When they say that 11042 and 11043 are only to be used for initial debridement, I wonder if they are thinking these codes are actually 11043 and 11044 (debridement of muscle and bone).

We have been having the same issues with WPS (Wisconsin) and no amount of appealing on our part has been successful. I would be very interested to hear if anyone else has had any success.

Laura
 

klbecker

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Hi Melissa,
I'm in Michigan and we are having the same issue with my wound care physician. We've submitted documentation, pictures and 1st and 2nd level appeals. WPS is sticking with their denial for "active wound care" even though my doctor removes and documents subcutaneous tissue. It is very frustrating.

Kristy
 
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Evansville, Indiana
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We are just now having an issue with this. We plan to appeal the claims that we have currently. I'm sure they will continue to deny them but I refuse to accept that as correct coding. We shall see.
 
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