Challenges And Conundrums With Wound Care Coding

These panelists provide a guide to tackling common coding dilemmas, appropriate coding for wound debridement, skin grafts and substitutes, and advice for new doctors when learning to code.

Q:

What is your advice for a new practitioner who is learning how to code and bill for your service?

A:

Kazu Suzuki, DPM, CWS, advises not waiting until you graduate from the residency program to learn how to code.

“I realize that often residents learn coding from their attendings or residency director, but I caution that practice unless your attending has learned the rules and codes,” says Barbara Aung, DPM. “The information you get may be more along the lines of ‘I’ve always done it this way’ rather than the rules dictating how a specific procedure should be coded and billed.”

Dr. Suzuki recommends subscribing to many online coding newsletters, attending in-person workshops and learning about ICD-10, and how to code diagnosis and procedures appropriately. For new practitioners just learning how to code and bill for services, Dr. Aung would recommend buying the CPT, ICD-10CM and HCPCS code books. She suggests reading the coding rules provided at the start of each chapter or section in the books.

For Jeffrey D. Lehrman, DPM, the first step is to read your Medicare Administrative Contractor’s (MAC’s) local coverage determination (LCD) for ulcer debridement. He says this will give clinicians an excellent idea of the coding options. Dr. Lehrman says the LCD explains what is covered, what is not covered and normally will even note what constitutes necessary documentation in order to support the service being billed, all of which is free information. Dr. Lehrman also suggests attending conferences and webinars on coding. For members of the American Podiatric Medical Association (APMA), Dr. Lehrman says there are coding webinars archived on the APMA website that can be helpful to a beginner in learning this type of material. There are also websites and forums you can subscribe to that can help.

Although the APMA has a great tool for members with its Coding Resource Center, Dr. Aung says using the digital formatted information in the Coding Resource Center may be a little harder.
Dr. Aung also advises not just knowing the codes and the coding rules, but also knowing the policies of each insurance plan that may dictate how the insurers will apply the rules. She also emphasizes having a strong understanding of how the insurance plan’s coverage policies affect your reimbursement. Dr. Aung says clinicians should also be well versed with the policies they must follow in their state (if the case involves Medicare).

Dr. Suzuki outsources his billing to a team of professional billing specialists.
“It is little too overwhelming and time-consuming for me to wear both hats (doctor and biller) at the same time,” concedes Dr. Suzuki.

Q:

How do you code wound debridement appropriately?

A:

Dr. Lehrman outlines the four main debridement codes.

97597. This code is for debridement (e.g., high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session; total wound(s) surface area; first 20 cm² or less.

11042. This is for debridement of subcutaneous tissue (includes epidermis and dermis, if performed); first 20 cm² or less.

11043. Use this code for debridement of muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 cm² or less.

11044. This code covers debridement of bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 cm² or less.

All the panelists note the coding is based specifically on the amount of wound one debrides. Dr. Suzuki has seen physicians make the mistake of coding on what they see of the wound, not what they debride of it. As he explains, even though one may see a tendon peeking through the wound a little bit, it is not a “tendon/muscle” level debridement unless the physician is debriding that presumably non-viable tendon.

Dr. Lehrman concurs. He says the code is based not necessarily on the depth of the wound debrided but rather on the deepest layer of tissue one removes. For example, he notes if the wound has exposed bone but the debridement only extends to the layer of subcutaneous tissue, and one removed less than 20 cm² of subcutaneous tissue, the correct code would be 11042.

Dr. Lehrman notes there are add-on codes for debridements of over 20 cm². If there are two wounds in which one debrided bone, Dr. Aung advises adding up the areas debrided and if it is less than or more than 20 cm², one should use the base code and the add-on code to describe the amount of bone debridement.

Q:

How do you code for skin grafting and skin substitutes?

A:

Dr. Suzuki says skin grafting (including skin substitute grafting) is separated by two groups of anatomical locations with one group being the trunk, arms and legs, and another group being the face, hands and feet.

Within each anatomic location, Dr. Aung says one is either applying less than 100 cm² or more than 100 cm² in total. When applying less than 100 cm², Dr. Aung says one should use a base code to describe the first 25 cm² and then use the add-on code three times to add up to 100 cm². If there is already more than 100 cm², she suggests starting with using the base code for the first 100 cm² (either in the foot or leg), and then employing the add-on code for any additional area up to the next 100 cm².

Dr. Suzuki notes the skin substitute codes are CPT 15271 to 15276.

Q:

What are the often misunderstood facts in coding and billing for wound care?

A:

Dr. Lehrman has found the biggest mistake is not understanding that the code is based on the deepest layer of tissue removed, not the depth of the wound itself. Dr. Aung agrees. She says if you remove slough with a blade, curette or scissors, but do not remove fat or muscle (yet muscle or fat is visible), you would only code the selective debridement code since you have only removed the slough.      

Dr. Lehrman stresses the importance of understanding that the area of tissue debridement at the same depth in multiple wounds is cumulative, regardless of the number of wounds. If two different wounds both have 3 cm² of subcutaneous tissue removed, he says the coding would be one unit of 11042 because the total amount of subcutaneous tissue removed was less than 20 cm².

Dr. Aung says another misperception with coding and billing is that if there is a code for a procedure or product, the insurance plan will pay it.

“This is not necessarily the case,” points out Dr. Aung. “Having a code does not directly translate to coverage for the procedure or the product so knowing the rules under which you must operate is a must.”

Another common error is not using the add-on codes properly, according to Dr. Lehrman. If removing over 20 cm² of tissue at a certain depth, he says to use the base code and the add-on code. For example, if removing 28 cm² of subcutaneous tissue, he notes the coding would be both 11042 and 11045.

Dr. Lehrman provides a summary of add-on codes below.

97598. This code is for debridement and is an add-on to code 97597 for each additional 20 cm², or part thereof. List this separately in addition to the code for the primary procedure.

11045. This code is for debridement of subcutaneous tissue and is an add-on to code 11045 for each additional 20 cm² or part thereof. List this separately in addition to the code for the primary procedure.

11046. This code is for debridement of muscle and/or fascia, and is an add-on to code 11043 for each additional 20 cm² or part thereof. List this separately in addition to the code for the primary procedure.

11047. This code is for debridement of bone and is an add-on to code 11044 for each additional 20 cm², or part thereof. List this separately in addition to the code for the primary procedure.

Since these are add-on codes, Dr. Lehrman says they do not take a 59 or 51 modifier.

“Documentation is still the key in proper coding and billing. Meticulous documentation of what you did for the particular patient is what backs up your coding and makes you audit-proof,” maintains Dr. Suzuki. Although he outsources his billing, he says delegating coding to other people (professional coders/billers) can at times be a problem for both over/under coding as the physician knows exactly what kind of procedure and examination happened in that particular exam room and operating room.

Q:

Do you have any pearls to add regarding coding and billing in wound care practice?

A:

Dr. Suzuki says CPT 29581 is a relatively new code that covers multilayer compression dressing for lower extremities. Since he applies these compression bandages multiple times in his wound care center, he advises not forgetting to bill for it and getting reimbursed for service.

Dr. Lehrman stresses knowing which group of codes to start with when choosing a diagnosis code for an ulcer. The ICD-10 considers a “wound” to be something traumatic and he says those are S codes. In the wound care field, sometimes the words “wound” and “ulcer” are interchanged as if they are synonyms, but Dr. Lehrman says one must be aware that in ICD-10 language, a wound is something related to a trauma whereas a chronic open sore is considered an “ulcer.”

Dr. Aung suggests monitoring the Medicare website for updates to local or national policies regularly, which she does once per quarter. She cites the APMA’s Coding Resource Center, which has quick links to each state’s policies.

Dr. Aung is in private practice in Tucson, Ariz. She is a Certified Professional Medical Auditor and a member of the American Academy of Professional Coders. She is also a panel doctor at Carondelet St. Mary’s Advanced Wound and Hyperbaric Center in Tucson. Dr. Aung serves on the examination committees for both the American Board of Wound Management and the American Board of Podiatric Medicine.

Dr. Lehrman is a Fellow of the American Academy of Podiatric Practice Management (AAPPM), serves as an expert panelist on Codingline.com and is on the APMA Coding Committee. Follow him on Twitter @DrLehrman .

Dr. Suzuki is the Medical Director of the Tower Wound Care Centers at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. He can be reached at Kazu.Suzuki@cshs.org.

For further reading, see “Essential Tips On ICD-10 And Wound Care Coding” in the November 2016 issue of Podiatry Today,  “Coding And Wound Care: What You Should Know” in the October 2015 issue, or “Pertinent Insights On Coding For Wound Care” in the July 2012 issue. To access the archives, visit www.podiatrytoday.com.