A Guide To Coding For Outpatient And In-Hospital Debridement

In order to ensure proper coding and timely reimbursement, it is essential to have a heightened awareness of recent changes to debridement codes. Accordingly, this author offers a closer look at the new codes and discusses criteria for selecting the proper codes.

Wound care has become a more prominent subspecialty in medicine. The number of wound care products, adjunct treatment modalities and treatment algorithms is constantly changing. Podiatrists are performing a significant amount of wound care. Proper coding of these treatment modalities is therefore very important.

   As of Jan. 1, 2011, there have been several coding changes that affect wound care billing. The CPT codes 11040 and 11041 have been deleted. This CPT code deletion impacts all insurance carriers that follow CPT coding guidelines.

   The proper selection of the remaining and the new CPT wound care/debridement codes is now based upon the type of tissue debrided, not just the depth of the wound (no real change there).

   In addition, as of Jan. 1, 2011, one must document the size of the wound(s) listed by dimension and/or in square centimeter size, and select billing codes based upon total aggregate size of similar wounds (based upon type of tissue debrided) regardless of where they are on the body. This billing protocol is consistent for all of the wound care debridement CPT codes valid as of Jan. 1, 2011.

Key Changes To Debridement CPT Codes

The CPT code series CPT 11010 -11012 description has changed to:

   CPT 11010. This indicates debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e.g., excisional debridement) as well as in skin and subcutaneous tissues.

   CPT 11011. This indicates debridement including removal of foreign material in skin, subcutaneous tissue, muscle fascia and muscle.

   CPT 11012. This indicates debridement including removal of foreign material in skin, subcutaneous tissue, muscle fascia, muscle and bone.

   CPT 97597-97598. This code series has had one of the more significant changes. Previously, these codes were to be used by non-physicians but now these codes are to be used by all providers who perform this service.

   The code description includes debridement (utilizing various means including sharp debridement) of devitalized epidermis or dermis, fibrin, exudate, debris, biofilm, etc. from open wounds. Again, the type of material/tissue documented as being debrided in the chart is key here. One could use this code series for debridement of the superficial fibrin, exudates, etc., from any wound including the base of deeper wounds when no specific deep tissue (subcutaneous, muscle, bone) is documented as being debrided.

Current Insights On Billing Wounds Per Aggregate Size

The other major change in wound care coding this year is that one cannot bill wounds per lesion. Rather, physicians should bill per aggregate size of all wounds in which they are debriding similar tissue.

   One would use CPT 97597 to bill for debridement of the first 20 cm² of aggregate wound size. Use CPT 97598 for any subsequent 20 cm² increments of debrided tissue. For example, if there are two wounds that have partial- or full-thickness debridement as described by CPT 97597, and one wound is 5 cm² and the other is 10 cm², the coding would be CPT 97597. Bill this once because CPT 97597 allows for up to 20 cm².

   On the other hand, if the first wound measured 10 cm² and the second wound measured 15 cm², then the aggregate of the two wounds would be 25 cm². The coding would then be CPT 97597 for the first 20 cm² and CPT 97598 for the remaining 5 cm². If the aggregate wound size for the two wounds is 50 cm², then proper billing will be CPT code 97597 for the first 20 cm² and CPT code 97598 — unit two in box 24G on the CMS 1500 form or ECS equivalent — for the remaining 30 cm² (20 cm² plus 10 cm²). One would bill CPT 97598 in 20 cm² increments or portion thereof.

   These wounds can be anywhere on the body. There are no bilateral T or F modifiers required. Furthermore, if you only bill these two codes together, there is no need to append any modifiers such as a 59 modifier to CPT 97598 when billing with CPT 97597. When it comes to both CPT 97597 and CPT 97598, you should bill these at their full allowed value. There is already a fee adjustment included in the allowance for CPT 97598. However, additional modifiers may be required if you are billing other services (procedures or E/M services) along with CPT 97597/97598 for the same visit.

   Note: Do not bill CPT 97597 and 97598 with CPT 11042-11047 as the latter codes include the skin debridement.

   Note: Do not use CPT 97597 and 97598 codes in a skilled nursing facility setting as they are part of skilled nursing facility consolidated billing protocols. Therefore, you should discuss this with nursing facilities for direct payment from them for these services.

   Note: Unna boot application will be allowed in addition to CPT 97597 and CPT 97598 by appending the dressing code CPT 29580/29581 with a 59 modifier.

Other Pertinent CPT Coding Changes

CPT codes 11040 and 11041. As I noted earlier, these codes have been deleted for all uses.

   CPT 11042. This code continues to address the debridement of wounds down to and including subcutaneous tissue. However, the descriptor has changed to debridement of subcutaneous tissue (which includes epidermis and dermis) for the first 20 cm² or less. Again, as with CPT codes 97597 and 97598, this code is for aggregate size of similar wounds (based upon the type of tissue debrided) for the first 20 cm² or less, not per wound.

   CPT 11045. This is a new code that was squeezed in between CPT 11042 and 11043 (it is out of sequence). This code is also for debridement of subcutaneous tissue (including epidermis and dermis) but clinicians can use this code for each additional 20 cm² increments or part thereof. One can bill this code in multiple increments. Again, do not use any modifiers when billing this code in conjunction with 11042 unless other procedures dictate the use of a modifier.

   CPT 11043. This has been changed to debridement of muscle and/or fascia (includes epidermis, dermis and subcutaneous tissue, if performed). This applies to the first 20 cm2 or less.

   CPT 11046. This is a new code that was squeezed in between 11043 and 11044 (it is out of sequence). Its description is debridement, muscle and/or fascia (includes epidermis, dermis and subcutaneous tissue) for each additional 20 cm² or part thereof. Bill this code in conjunction with CPT 11043.

   CPT 11044. This has been changed to debridement of bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed). It applies to the first 20 cm² or less.

   CPT 11047. This is a new code for debridement of bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia) for each additional 20 cm² or part thereof. Bill this code in conjunction with CPT 11044.

How To Select The Correct Debridement Codes

In summary, select the CPT codes 97597/97598 and 11042-11047 based upon the following three criteria.

   1) The type of tissue debrided, not necessarily the depth of the wound. If you only debride subcutaneous tissue on a wound that has bone exposed, you would still only bill CPT 11042 as subcutaneous tissue is what you debrided from the wound.

   2) The aggregate size of the wounds based upon 20 cm² increments, not the number of individual wounds.

   3) If there are multiple wounds from which you have debrided a different tissue type, lump all similar wounds (based on the type of tissue you have debrided) together.
For example, if debriding bone from wound #1 (< 20 cm²), bill CPT 11044. If debriding muscle from wound #2 (<20 cm²), then also bill CPT 11043 -59 for the second wound since you are debriding different tissue. Append the lesser debridement code with the 59 modifier.

   On the other hand, if the above scenario includes debridement of bone from wound #1 (<20 cm²) and debridement of muscle from multiple wounds with an aggregate of 30 cm², billing would be CPT 11044 for wound #1 (<20 cm²) and CPT 11043-59 (for the first 20 cm²) along with CPT 11046 for the additional >20 cm2 debrided for the other combined similar wounds.

   You can mix and match all combinations of CPT code 11042-11047 based upon the tissue you have debrided and the aggregate size of the wounds. Use 59 modifiers to separate out each principal debridement code (versus add-on codes).

   The global period for all debridement codes is now “zero” days. Keep in mind that the wound debridement codes may still be impacted from the global period of other procedures (such as amputation or other surgery) you may have performed.

Ensure Proper Coding For Wound Preparation For Grafting And NPWT

Preparing a wound for application of skin grafts, skin substitutes or skin flaps may require tissue debridement. Applying a negative pressure wound therapy (NPWT) device may also require tissue debridement. The goal is that wounds treated with these modalities will heal by primary intention or NPWT. Use CPT codes 15002-15005 for tissue debridement for this. These codes are listed in 100 cm² increments.

   Do not use these codes for wounds in which the intent is that they will heal by secondary intention. For these wounds, use the active wound care codes, which are CPT 97597-97598 and 11042-11047.

   Do not use CPT codes 15002-15005 in conjunction with the application of tissue cultured allogenic skin substitutes.

   Clinicians commonly use vacuum assisted closure (VAC) devices as adjunctive therapy after wound debridement. The two codes for the application of the VAC device are: CPT 97605 for a wound diameter of less than or equal to 50 cm² and CPT 97606 for wounds greater than 50 cm². CPT 97606 is not an add-on code so do not bill these two codes together. Only bill one or the other.

   When billing these codes, you must list your national provider identifier (NPI) number in box 17 in order to receive payment.

   Dr. Poggio is a California Podiatric Medicine Association Liaison to Palmetto GBA Medicare J1 MAC and is a medical consultant to several national health insurance and review organizations. He is a member of the American College of Podiatric Medical Reviewers and is board certified by the American Board of Podiatric Medicine and the American Board of Podiatric Orthopedics.

   For further reading, see “Key Pearls On Coding For Bunionectomies” in the February 2010 issue of Podiatry Today or “Key Coding Insights For Skin And Wound Conditions” in the October 2004 issue.