How Does Your Documentation Measure Up to Medicare Standards? Debridement 101

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To our readers: This article is the beginning of a series of articles on proper documentation practices for wound care. In this series, I will discuss different topics in wound care documentation practices that I have seen in my travels and found to be insufficient in light of Medicare’s documentation requirements.

Some of these issues could be due to handwritten notes while others may come from your electronic medical record. It is always a good idea to review records that are printed off and sent to payers as there may be some glitches in the documentation that can negatively impact the provider on audit.

A good way to utilize these articles will be to perform a self-audit on the topics presented to see how your documentation measures up to the current Medicare Administrative Contractor’s (MAC) documentation requirements in your own jurisdiction. As always, examples from Medicare Contractor documentation requirements may be used; however, it is the reader’s responsibility to look at the current Local Coverage Determination (LCD) in their own jurisdiction to ensure compliance with its listed documentation requirements. If you believe that an auditor has made an error in reviewing your documentation, you should appeal their findings and identify parts in the record and the known requirements that support your position. A sample audit tool will be provided as part of each article that you may wish to utilize to evaluate your own documentation practices.

This first article in the series contains information on the topic of debridement. Debridement has been heavily scrutinized by various auditors, government agencies and insurers. Since this seems to be one of the hottest topics in wound care, I thought we would start with the documentation requirements for debridement. This article will not focus on burn debridement or burn excision codes.

The CPT Codes

The specific set of codes that we will be using to discuss debridement are as follows:

11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

11045 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure)

11046 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure)

11047 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure)

97597 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

97598 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure)

Note: Some coverage policies state that debridement of fibrin and biofilm are considered part of an Evaluation and Management (E/M) visit. If you look carefully at the codes 97597 and 97598 you will note that Debridement of … fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm is clearly included in those code descriptions.

Debridement (CPT 11042–11047) Debridement codes are selected based on the actual type of tissue removed from the wound as well as the surface area of the wound. Surgical debridement includes going slightly beyond the point of visible necrotic tissue until viable bleeding tissue is encountered in most cases. The use of a sharp instrument does not necessarily substantiate the performance of surgical debridement. The medical record should show that a surgical debridement has been performed with tissue removed such as subcutaneous tissue, muscle or bone down to healthy bleeding tissue. The most important point to remember is to code the depth of tissue removed, not the depth of tissue the provider can see. For example, you may see bone in the base of the wound during the procedure; however, if there was only subcutaneous tissue removed, then the debridement would be coded to subcutaneous, not to bone.

Selective Debridement (CPT 97597 and 97598) Selective debridement refers to the removal of specific, targeted areas of devitalized tissue or tissue that limits healing from a wound along the margin of viable tissue. Occasional bleeding and pain may occur. Be careful of terminology as many clinicians use different terminology for the same procedures. For example, conservative sharp debridement is a minor procedure that requires no anesthesia and is performed on an outpatient basis. Scalpel, scissors, and tweezers/forceps may be used and only clearly identified necrotic/devitalized tissue is removed. Generally, there is no bleeding associated with this procedure. As a reminder, simply stating sharp debridement does not put the debridement into the 11042–11047 series. You will note that sharp selective debridement with scissors, scalpel or forceps is in the code description of 97597. 

Documentation Elements

1.    For each wound, describe any previous treatments and the response to the treatments. Remember: each procedure must be deemed medically necessary.

2.    Is the diagnosis reported for that encounter on the list of ICD-10-CM codes applicable to the policy?

3.    Describe etiology of wound and how underlying cause is being addressed.

4.    On every debridement procedure describe the wound in terms of length x width x depth. Pre- and post-debridement measurements should be recorded. Grid drawings and/or photos are recommended.

5.    Describe the wound composition in detail such as % granulation tissue, % devitalized tissue, and % other tissue totaling 100% of the wound accounted for.

6.    Is there evidence of infection, undermining or tunneling?

7.    Document exact types of tissue removed from the wound such as epidermis, dermis, subcutaneous, muscle and bone, fibrin, slough, biofilm, devitalized tissue.

8.    Document the type of tissue removed from the wound—not what tissue you see. For example, you may see bone in the wound. However, if you only remove muscle you may only code debridement of muscle. In addition, if muscle was previously debrided and a second debridement is performed and only exudate and biofilm are removed, code 97597, not debridement of muscle.

9.    Describe what instruments and any anesthetics if used.

10.    Document what intervals the wound will be debrided—daily, weekly etc.

11.    Are aftercare and next appointment documented?

12.    Is the result of previous debridement documented?

These are not the only guidelines on debridement. There are numerous valuable references and guidelines regarding debridement. It is very important to be aware of your Medicare Local Coverage Determination for wounds. Be sure to print it and have a copy handy as a reference and compare to the templates of your electronic health record to ensure that all the elements required are present in the templates and any other documentation forms that are used in the practice.

As you can see, many audit organizations are also reviewing for these same criteria. As promised, I have provided an audit template for our readers to utilize to perform a self-audit of their debridement documentation. It is a good idea to review electronic records to ensure that all debridement documentation elements are present. Periodic review of your documentation will result in passing any audit with flying colors.

Hopefully this article and audit tool will assist you in evaluating your debridement documentation practices. Use the results of your internal audit as a basis for education pertaining to opportunities for improvement. Stay tuned for the next article on improving wound care documentation practices.

Donna Cartwright is senior director of health policy and reimbursement at Integra LifeSciences Corp., Plainsboro, NJ. She is approved as an AHIMA-approved ICD-10-CM/PCS trainer and she has been designated as a fellow of the American Health Information Management Association.
 

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