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Debridement of preulcerative lesions

  1. #1
    Default Debridement of preulcerative lesions
    Medical Coding Books
    We have several patients who are either diabetic or have PVD who have resolving or resolved ulcerative lesions. We have been getting denials for services provided pertaining to these patients. The keratotic skin over the lesion must be removed to evaluate and treat the skin underneath. Since we lost codes 11040/11041 we have been billing code 11055 or 11056 with the PCP last date seen, Q modifier, ulceration dx code and DM/PVD code all as part of the claim. Sometimes, but not always, is the skin overlying the wound site is infected.

    We practice in Kansas and have just recently began getting denials for "max units by this provider for this period" for these codes. The LCD indicates codes 11055/11056 can only be billed every 60 days. Call WPS Medicare has not resolved the issue as we have been told several times, they absolutely will not pay for this claim this often even though the patient has DM/PVD. As you all know, these patients have to be evaluated frequently due to their DM/PVD issues or there is a threat of limb loss if ulcers are left untreated for 60 days.

    Any suggestions or help on resolving this very frustrating issue would be appreciated.

  2. #2
    Location
    Flint, Michigan
    Posts
    65
    Default
    CPT codes 11040 and 11041 have been eliminated; they are replaced by CPT codes 97597 and 97598 as appropriate for débridement of dermal and epidermal skin layers.

  3. #3
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Quote Originally Posted by hsheeley View Post
    We have several patients who are either diabetic or have PVD who have resolving or resolved ulcerative lesions. We have been getting denials for services provided pertaining to these patients. The keratotic skin over the lesion must be removed to evaluate and treat the skin underneath. Since we lost codes 11040/11041 we have been billing code 11055 or 11056 with the PCP last date seen, Q modifier, ulceration dx code and DM/PVD code all as part of the claim. Sometimes, but not always, is the skin overlying the wound site is infected.

    We practice in Kansas and have just recently began getting denials for "max units by this provider for this period" for these codes. The LCD indicates codes 11055/11056 can only be billed every 60 days. Call WPS Medicare has not resolved the issue as we have been told several times, they absolutely will not pay for this claim this often even though the patient has DM/PVD. As you all know, these patients have to be evaluated frequently due to their DM/PVD issues or there is a threat of limb loss if ulcers are left untreated for 60 days.

    Any suggestions or help on resolving this very frustrating issue would be appreciated.
    Are you using the diabetes as your first listed dx code with the 4th digit of 8? if you are listing the ulcer code first this could be the issue.

    Debra A. Mitchell, MSPH, CPC-H

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