Business Briefs: Debridement Reminders Issued by OIG and Payors

  The Office of Inspector General (OIG) Work Plans for the past few years include a study to determine the extent to which Medical Part B surgical debridement services met Medicare program requirements. The findings from the May 2007 OIG Report, Medicare Payments for Surgical Debridement Services in 2004 (available at: http//:oig.hhs.gov/oei/reports/oei /02-05-00390.pdf) offer several important insights.

  In 2004, 64% of surgical debridement services did not meet Medicare program requirements, resulting in approximately $64 million in improper payments. Of these, 39% were miscoded, 29% had insufficient documentation, and 1% were deemed medically unnecessary (overlapping errors = 5%). In addition, most carriers had local coverage determinations (LCDs) and edits in place but conducted limited medical review of surgical debridement services.

  Subsequently, the OIG made recommendations (agreed to by the Centers for Medicare and Medicaid Services [CMS]) that ask Medicare contractors to strengthen program safeguards and prevent improper payments for surgical debridement services, clarify information that needs to be documented in the medical record to meet Medicare program requirements, implement edits (eg, frequency edits), and conduct medical reviews and educational efforts regarding surgical debridement services, such as 1) what services are considered surgical debridement, 2) how these services should be coded, and 3) when modifiers may be used.

Debridement Medical Policies

  Many Medicare contractors responded to the OIG Work Plans by developing LCDs regarding chronic wound debridement. In February 2007, this author compiled a listing of the LCDs that pertained to chronic wound debridement and presented the list at the Symposium on Advanced Wound Care (SAWC) Satellite Meeting, “Debridement: Clinical and Economic Realities.” This list showed that Medicare Carriers and Fiscal Intermediaries already had implemented chronic wound debridement LCDs in more than half of US states. The LCDs contain important information for wound care professionals, including:
    • Indications and limitations of coverage and/or medical necessity
    • CPT® codes, covered/non-covered
    • ICD-9 codes that support/do not support medical necessity
    • Documentation guidelines
    • Utilization guidelines
    • Attachments — eg, coding guidelines.

  Wound care providers should carefully study their Medicare contractors’ LCD(s) and Articles that pertain to debridement. If the hospital outpatient department (HOPD) does not know the name of its Medicare contractor, the program director or medical director should contact the hospital billing office. Physicians are similarly advised to contact their billing manager(s) or billing company(ies) for the name of their Medicare contractors. Note: The Medicare contractor for the HOPD and for the physician(s) providing wound care services in the HOPD may not be the same.

  If a Medicare contractor does not already have an LCD/Article regarding chronic wound debridement, the sections of the website where Articles and draft medical policies are posted should be continually monitored. Because the OIG and the CMS agree that Medicare contractors should provide debridement direction, all the contractors will eventually release Articles and/or LCDs that cover debridement, if they have not already done so.

Providing Debridement Education

  Once the LCDs and Articles that pertain to your HOPD and the physicians who work there have been located and printed, your certified coder(s) should be asked to provide inservices to your entire professional staff. Several important topics should be covered:

  AMA code descriptions and clinical examples. The American Medical Association (AMA) provides CPT® code descriptions and clinical examples for surgical excisional, selective, and non-selective debridement. Five CPT codes (11040 through 11044), specific to surgical excisional debridement, are based on the level of skin, subcutaneous tissue, muscle, and bone that is excised. The skin alone or along with subcutaneous tissue, muscle, and bone is excised until viable bleeding tissue is encountered. These codes often coincide with anesthesia (see Table 1 for the AMA’s definitions of these codes). Note: The surgical excisional debridement codes are based on what is removed, not on the depth of the wound. Wound care providers also are cautioned not to report these codes in conjunction with codes 97597, 97598, and 97602, which are based on the removal of devitalized tissue and/or necrotic tissue to promote healing. Anesthesia is never a part of these debridements (see Table 2 for the AMA’s definitions of these codes). Note: These codes are not intended to report dressing changes. If the wound does not need debridement, dressing changes should be included in the HOPD’s clinic visit level mapping system. Wound care providers also are cautioned not to report these codes in conjunction with 11040 through 11044.

  For clarification, selective debridement describes a situation where the wound care provider has complete control over which tissue is removed and which is left behind. Selective techniques include high-pressure waterjet with/without suction and sharp debridement using scissors, scalpel, or forceps.

  Non-selective debridement, often referred to as mechanical debridement, involves the removal of both necrotic and healthy tissue. Some techniques include wet-to-moist dressings, non-selective enzymes, and abrasion.

  Routine foot care (such as removal of a benign hyperkeratotic lesion, corn, or callus) should be billed with CPT codes 11055 through 11057. Note: These codes are considered routine foot care and are usually not covered by Medicare.

  Staff also should be instructed to review Medicare’s guidance for use of modifiers, such as modifier 59, distinct procedural service, and modifier 79, unrelated procedure or service by the same physician during the postoperative period. Physicians and HOPDs should be sure their use of modifiers with surgical excisional debridements complies with Medicare’s guidance.

  LCDs and Articles. Medicare contractor(s)’ LCD(s) and Article(s) pertinent to HOPDs and physicians should be reviewed carefully and thoroughly. Some Medicare contractors identify the place of service where various levels of surgical excisional debridement may be safely performed. Some contractors limit the number of surgical excisional debridements that may be performed on a single wound per year.

  Documentation. Surgical excisional debridement and active wound management (selective and non-selective debridement) procedures require documentation within the following guidelines:
    • The physician should diagnose the patient on each visit.
    • The wound should be photographed before and after each procedure.
    • The condition of the wound should be documented before and after each procedure.
    • A CPT® code should be selected that correlates with the work performed and documented. For each procedure, clinicians should remember that surgical excisional debridements, like the application of skin substitutes, are in the surgical section of the CPT book. Therefore, they require an operative/procedure report.

Pay Per Level of Debridement

  Physicians often are surprised to learn that the active wound management selective and non-selective debridement codes are appropriate to describe the various typical non-surgical maintenance debridements that they perform. The AMA clearly states that any procedure or service in any section of the CPT® codebook may be used to designate the services rendered by any qualified physician or other qualified healthcare professional. Physicians are equally surprised to learn that the codes have fees on Medicare’s Physician Fee Schedule. This is a classic example of why providers must acquire and study the annual updates of the various coding and payment systems, which frequently are modified and updated. Wound care professionals must monitor these changes and incorporate them into their super bills, charge sheets, chargemasters, and the like.

  Originally, the active wound management codes were created for wound care nurses and physical therapists to track their wound management work. In fact, the original active wound management codes did not have any assigned Medicare payment rates. Later, the code numbers and definitions were revised — beginning in 2006, the CMS assigned payment rates to the selective debridement codes (97597/97598) on both the HOPD and physician fee schedules and to the non-selective debridement code (97602) on the HOPD fee schedule only. Table 3 and Table 4 present an overview of the 2007 national average Medicare payment rates for the various levels of debridement performed by wound care professionals.

The Bottom Line

  When HOPDs and physicians discover that all chronic wound debridements are not surgical excisional debridements, they often respond by asking if they will lose money by using the correct codes. Wound care professionals must remember that they are responsible for selecting the correct procedure for chronic management at every patient visit. Procedures should not be selected based on their level of reimbursement — in fact, that is one of the primary impetuses for the OIG Debridement Report.

  Wound care professionals should be proactive personally and through their professional societies if state-of-the-art wound care procedures and/or products do not have CPT/HCPCS codes, do not have payment rates, have inappropriate payment rates, have inappropriate global periods, and/or have Articles and LCDs that are not consistent with specialty society guidelines (such as the Wound Healing Society Guidelines), FDA-approved package inserts, and published clinical trials. Just as a multidisciplinary team is required to manage wounds, professionals need to work with the organizations that create the codes, payment systems, and coverage determinations pertinent to chronic wound management.

  Kathleen D. Schaum, MS, is President of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleendschaum@bellsouth.net.

  Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.