Reimbursement Tips for Bariatric Surgery & Various Forms of Debridement

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

  This installment of “Business Briefs” will provide the reimbursement aspects of two clinical topics being covered in this issue of Today’s Wound Clinic: bariatric surgery and debridement.

  First, we will explain how documentation by wound care professionals who care for morbidly obese patients living with chronic wounds helps determine whether a payer will cover and pay for various types of bariatric surgery. Just as reimbursement is important to hospital-based outpatient wound care departments (HOPDs) and qualified healthcare professionals (QHPs), reimbursement is very important to patients. In fact, coverage and reimbursement by payers often is the deciding factor on whether the patient undergoes bariatric surgery.

  Second, we will provide some documentation and coding tips pertaining to the various forms of debridement.

Bariatric Surgery Documentation Tips

  Diabetic ulcer patients seen in the HOPD may also live with morbid obesity that complicates the course of treatment and rate of ulcer closure. To that end, QHPs may need to refer these patients to a bariatric service for assistance with obesity management. However, a QHP’s referral alone, without medical record documentation that justifies medical necessity for treatment of the morbidly obese patients, is inadequate.

  Medical necessity requirements for a payer to authorize one of the various forms of bariatric surgery are very specific and require extensive medical record documentation over time. Table 1 provides a few examples of the payer’s medical necessity requirements. As you can see, many payers have the same/similar documentation requirements. If QHPs, dietitians, and mental health professionals believe that bariatric surgery may benefit patients living with chronic wounds, they should refer to the Table for the criteria that must be met before a patient can obtain authorization from the payer for a bariatric surgical procedure. Then, these professionals can begin to help build their patients’ cases for medically necessary bariatric surgery through their medical record documentation. TIP: Wound care QHPs, dietitians, and mental health professionals should visit the website of the morbidly obese patient’s payer and read that payer’s current medical policy pertaining to bariatric surgery.

  Even though most bariatric surgery medical policies are very lengthy, they clearly outline the documentation required to build the case for bariatric surgery that will be covered and reimbursed. For questions regarding the information in the Table and/or in a particular payer’s medical policy, contact that payer for clarification.

Debridement Documentation & Coding Tips

  Two years ago, the debridement codes, descriptions, and introductory language in the surgery and medicine sections of the Current Procedural Terminology (CPT®) book were significantly revised. Also around that time, the Medicare Administrative Contractors (MACs) released local coverage determinations (LCDs) pertaining to debridement. One might think that by 2014 all wound care providers would clearly understand the debridement codes and the LCD guidance from the MACs that process their claims.

  While many wound care providers have done an excellent job of 1) incorporating the revised codes into their documentation, charging, and billing systems; and 2) downloading, printing, and educating all wound care professionals about their LCDs, a large number of wound care providers have not taken the time to do this important work. Many providers require “help” when debridement claims are denied, when MACs recoup payment for improperly paid debridement claims, and when billers dispute incorrect debridement coding and documentation practices.

  The many methods of debridement discussed should be a signal that wound care providers must clearly document and code their work. Following are some debridement documentation and coding tips to help prevent denials and repayments. Give yourself and your wound care team applause if you have 100% compliance with each tip. If you do not have 100% compliance with each tip, make a promise that you will begin immediately to make the corrections necessary to reach 100% compliance.

    1) Review the debridement codes in the 2014 CPT book:
      a) Introductory language of two subheadings:
        • Surgery Guidelines section, Integumentary System heading, Debridement subheading (found in book before CPT code 11000)
        • Medicine Guidelines section, Physical Medicine and Rehabilitation heading, Active Wound Care Management subheading (found in book before CPT code 97597)

      b) Actual code descriptions for 11000-11001, 11004-11006, 11008, 11010-11012, 11042-11047, 97597-97598, 97602, and 97605-97606.

    2) Note that all debridement codes are distinguished by the level of tissue debrided, not by the terms “excisional,” “sharp,” or “maintenance”. In fact, both surgical and medical debridement can be performed with a sharp instrument.

    3) Read the medical policies pertaining to debridement that are available from:
      a) The MAC that processes your Medicare claims;
      b) The top 20 payers who insure the majority of your patients living with chronic ulcers.
        ** Pay particular attention to each payer’s guidance about medical necessity/limitations, utilization guidelines, coding instructions, photography before/after debridement, measurement of ulcer before/after debridement, frequency and maximum numbers of debridements covered, documentation guidelines, etc.

    4) Document a full description of the debridement procedure performed per the medical policy guidelines. Be sure to document ulcer size prior to debridement, instrument/device/biologic used to perform debridement, exact level of tissue debrided, number of sq cm debrided, size of ulcer post-debridement, etc. Do not document such things as “debrided to subcutaneous tissue,” “debrided 50% of ulcer,” “sharp debrided the ulcer,” “selectively debrided the ulcer,” etc. NOTE: The professional who performs the debridement should document the work in the medical record. It is not acceptable for a QHP to ask a wound care nurse to document the debridement performed by the QHP.

    5) Document the ulcer size, in sq cm, before and after debridement. If entire ulcer is debrided, select the code that represents the after-debridement size of the entire ulcer. If ulcer is partially debrided, select the code that represents the after-debridement size of only the debrided portion of the ulcer.

    6) Code for the “level of tissue debrided,” not the depth of the ulcer “that you see.”

    7) Sum the total number of sq cm of the same tissue type debrided when multiple ulcers are debrided at the same visit. Eg: If the QHP debrided 15 sq cm of subcutaneous tissue from an ulcer on the right foot, 15 sq cm of subcutaneous tissue from an ulcer on the left foot, 10 sq cm of muscle from another ulcer on the right leg, and 15 sq cm of epidermis and dermis from another ulcer on the left leg, the HOPD and QHP should submit the following codes (if the documentation described each procedure specifically):
        • 11042 - 1 unit (for the first 25 sq cm of debrided subcutaneous tissue);
        • 11045 - 1 unit (for the additional 5 sq cm of debrided subcutaneous tissue);
        • 11043 - 1 unit (for the 10 sq cm of debrided muscle); and
        • 97597 - 1 unit (for the 15 sq cm of epidermis and dermis).

    8) Use the code that represents the “actual debridement performed,” not the code with the “best reimbursement rate.”

    9) Use the nonselective debridement code 97602 in HOPDs when the QHP writes a specific debridement order that says something similar to “apply enzymatic debridement ointment to debride the ulcer.” If the QHP does not write a “debridement order,” the HOPD cannot code for the enzymatic debridement.

    10) Do not use code 97602 in HOPDs when the only work performed is a dressing change. This code can only be used when a debridement order is written.

    11) Do not perform any form of debridement in an HOPD until a QHP has written the order for the procedure. This includes debridement with wet-to-dry dressing changes, pulse lavage, whirlpool, debridement with negative pressure wound therapy (NPWT), autolytic debridement, maggot debridement therapy, enzymatic debridement, surgical debridement of subcutaneous tissue/muscle/bone, and selective debridement of epidermis/dermis/fibrin/slough/biofilm, etc.

    12) Use the codes 97605-97606 in an HOPD when the QHP writes an order for the wound care nurse to debride the wound by applying a traditional NPWT pump and dressings. QHPs should not report these codes if they did not actually apply the equipment and dressings.

    13) Do not report two types of debridement for the same ulcer at the same visit. Eg: If the QHP debrides 40 sq cm of muscle on the left leg and writes an order for the HOPD staff to apply enzymatic debridement ointment to the same wound for continuous debridement:
      a) The QHP should report the following codes if the documentation supports the work:
        • 11043 - 1 unit (for the first 20 sq cm of muscle debrided) and
        • 11046 - 1 unit (for the additional 20 sq cm of muscle debrided).

      b) The HOPD should report the following codes if the documentation supports the work:
        • 11043 - 1 unit (for the first 20 sq cm of muscle debrided) and
        • 11046 - 1 unit (for the additional 20 sq cm of muscle debrided).

  NOTE: The HOPD should not report 97602 in this example.

  Donna J. Cartwright is an American Health Information Management Association-approved ICD-10 trainer and senior director of strategic reimbursement at Integra LifeSciences Corp., Plainsboro, NJ. She may be reached at 609-936-2265 or donna.cartwright@integralife.com. Kathleen D. Schaum is director, medical products reimbursement, biotherapeutics at Smith & Nephew Inc. and president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She may be reached for questions and consultation at 561-964-2470 or kathleendschaum@bellsouth.net.