Don’t Select Codes by the Payment Rate You Like

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At many reimbursement education/consultation venues in 2019, this author had to remind the wound/ulcer management professionals and providers not to select codes based on the payment rate they like. This topic usually surfaced during discussions about coding and reimbursement for surgical debridement (11042–11047) and selective debridement (97597–97598). This month’s Consultation Corner pertains to correct coding for debridement. 

Scenario

Physicians and other qualified healthcare professionals (QHP) often shared their frustration about the peer pressure they received pertaining to coding and billing for debridement. They reported that when a patient presents with a new wound/ulcer that requires debridement, they usually perform a thorough surgical debridement (if subcutaneous tissue, muscle, or bone is debrided) or selective debridement (if epidermis, dermis, fibrin, exudate, debris, or biofilm is debrided) during the first visit. In subsequent visits, if the wound/ulcer requires further debridement, they usually perform selective debridement and/or order some form of non-selective debridement. 

The physicians and QHPs also reported that their peers always use surgical debridement codes, no matter what level of tissue they debride. Their peers say that the selective debridement codes are only for use by therapists. Then their peers usually remind them that selective debridement has a much lower Medicare allowable payment rate than the rate for surgical debridement. 

The physicians and QHPs who work in hospital owned outpatient wound/ulcer management provider-based departments (PBDs) reported that they are further frustrated when the PBD reminds them that the PBD, physicians, and QHPs receive higher payments if the physicians/QHPs document that surgical debridement was performed. 

Facts to Consider

• All the codes in the CPT^®1 manual are pertinent to physicians/QHPs unless 1) the code descriptions exclude them, or 2) the State Practice Acts or hospital bylaws disallow certain professionals to perform certain procedures.  

• The American Medical Association revised the surgical debridement and selective debridement codes in 2011. The introduction to the debridement section of the CPT^® manual clearly states that “Wound debridements are reported by depth of tissue that is removed and by surface area of the wound.” 

• 11042 and 11045 should only be reported if subcutaneous tissue (includes epidermis and dermis, if performed) is debrided.

• 11043 and 11046 should only be reported if muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed) is debrided.

• 11044 and 11047 should only be reported if bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed) is debrided.

• 97597 and 97598 should be reported for debridement of open wounds if fibrin, devitalized epiderms and/or dermis, exudate, debris, or biofilm is debrided. 

• Procedure codes should always be selected based on the actual work performed, documented, and photographed. Procedure codes should not be selected based on the allowable payment rate that wound/ulcer management providers and professionals prefer. 

• During pre-payment and post-payment audits, payers 1) can consider claims with incorrect debridement codes to be false claims and 2) can invoke repayments up to 3 times the amount incorrectly paid.   

Consultation 

During educational programs and teleconsultations conducted throughout this year, I took the time to show the participants the current CPT^® manual, as well as the discussion about the surgical debridement and selective debridement codes in the American Medical Association’s CPT^® Changes 2011: An Insider’s View. I also reviewed some deidentified examples of large repayments that have been made for reporting surgical debridement when selective debridement was actually performed. Finally, I reminded the physicians/QHPs that total cost of care is now counting toward their quality payment program bonus or penalty. Therefore, they should be doing everything possible not to unnecessarily inflate their reported cost of care. And as always, they should provide and report the right care, at the right time, and in the right amount!

Summary

All wound/ulcer management professionals and providers own the responsibility of knowing the codes and the code descriptions for the services and procedures they perform. Because we are now entering the 10th year since the debridement codes have been revised, misuse of these codes is unexcusable. I always give kudos to the physicians/QHPs who continue to code correctly, even when they are being pressured to code incorrectly, and always do my best to encourage all physicians, QHPs, and providers to do the right thing! 

Finally, I always remind everyone that the financial consequences of submitting false claims should be a sufficient reason to select the debridement code that describes the level of tissue debrided, not the code that has the payment rate that they like best.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net. 

1. CPT is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT^®) is copyright 2019 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.