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Why Is Debridement Coding Such a Mystery?
Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.
At the 3-hour Symposium on Advanced Wound Care (SAWC) Spring reimbursement post-conference, this author/speaker prepared more than 40 interactive coding, payment, and coverage scenarios for the attendees to assess their knowledge. The topics of the scenarios were carefully selected and included a balance of coding for frequently performed services, coding that is typically denied or recouped upon audits, coding and payment for new services and procedures, and new coding, coverage, and payment for new procedures.
Surprisingly, the attendees spent the most time asking questions about a topic that should be well-known and understood by all wound/ulcer management physicians and other qualified healthcare professionals (QHPs): coding and payment for debridement. The amount of misinformation that existed about these codes, which have been in place since 2011, was astonishing.
Because debridement is frequently performed by physicians, QHPs, and therapists, and because the Medicare audits have resumed, all wound/ulcer management professionals should 1) proactively take the time to learn the debridement coding and documentation guidelines, 2) seriously audit their own documentation and coding for debridement, and 3) immediately refine aberrant debridement documentation and coding practices.
Debridement coding and documentation guidelines are clearly delineated by the American Medical Association and by the Medicare Administrative Contractors. However, claims processing software often incorrectly pays for debridement codes that should not have been paid. Then when the payers conduct post-payment audits, they often find that the documentation in the medical record does not support the debridement codes reported, and the recoupments begin! In fact, a recent post-payment audit, conducted on 1 debridement code (11042) reported in 3 major states, found that 38% to 52% of the claims were incorrectly paid. Therefore, this author/consultant believes that now is the time for each professional who performs debridement procedures to solve the unnecessary mystery surrounding debridement documentation and coding.
The first step is to assess your own knowledge. The following self-test will help you do just that. The only acceptable score is 100%. If you do score 100% on the test, audit your actual coding practices to ensure they align with your coding knowledge. If you do not achieve 100% on the test, study the coding and coverage guidelines about that topic, and then audit your actual coding practices to ensure they align with the coding guidelines. If your coding practices do not align with the debridement coding and coverage guidelines, immediately take the appropriate steps to make the necessary corrections. Check your answers with the attached answer sheet. Click here to download the self-test as a PDF.
Then, before June 15, 2022, click here to take the anonymous simple 5 question survey which will help this author provide future debridement education link goes here before June 1, 2022. Good luck unraveling the debridement mystery!
Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.
| 1 |
Physicians and other qualified healthcare professionals (QHPs) should not report 97597/97598 on their claims because those codes are only appropriate for therapists. |
| 2 | When a physician’s/QHP’s documentation states that she/he performed a “sharp debridement,” the correct code(s) to report on claims is/are always 11042–11047. ☐ True ☐ False |
|---|---|
| 3 | When a physician/QHP documents that “excision” was performed, she/he should always report code(s) 11042–11047 on claims. ☐ True ☐ False |
| 4 | When a physician/QHP visualizes bone, she/he should always report debridement code(s) 11044/11047 on claims. ☐ True ☐ False |
| 5 |
Physicians/QHPs/therapists are not required to document the portion of the debrided wound/ulcer in sq cm. |
| 6 | When a physician/QHP debrides 5 sq cm of subcutaneous tissue from an ulcer on the left leg and 10 sq cm of subcutaneous tissue from an ulcer on the right leg, she/he should report these codes, modifiers, and units on the claim: 11042RT (1 unit) 11042LT (1 unit) ☐ True ☐ False |
| 7 |
When a physician/QHP debrides epidermis and dermis from an open ulcer on the right foot, she/he should report this code, modifier, and unit on the claim: |
| 8 | A physician/QHP debrides 10 sq cm of subcutaneous tissue from an ulcer on the right leg and 20 sq cm of subcutaneous tissue from an ulcer of the left leg. Select the correct code, modifier, and unit(s) that should be reported on the claim. A. 11042RT (1 unit) and 11042LT (1 unit) B. 11042 (1 unit) and 1104559 (1 unit) C. 11042 (1 unit) and 11045 (1 unit) D. 11042RT (10 units) and 11042LT (20 units) E. None of the above |
| 9 | Wound/ulcer debridement codes 11042–11047 are reported by the depth of tissue that is removed and by the surface area of the wound/ulcer. ☐ True ☐ False |
| 10 |
A physician/QHP debrided 15 sq cm of subcutaneous tissue from an ulcer with exposed bone; the correct code(s), modifier, and unit(s) to report on the claim are: |
| 11 |
Select the true statement about modifier 59. |
| 12 |
Select the appropriate modifier(s) to use when the physician/QHP debrides 15 sq cm of subcutaneous tissue from a venous ulcer on the right leg and 5 sq cm of muscle from a venous ulcer on the left leg. |
| 13 | Select the appropriate modifier(s) to use when the physician/QHP debrides 8 sq cm of subcutaneous tissue from a venous ulcer on the right leg and 2 sq cm of bone from an ulcer on the right foot. A. RT Right and LT Left B. 59 Distinct procedural service C. XS Separate structure D. B or C E. None of the above |
| 14 | Because the description of modifier 59 is distinct procedural service, physicians QHPs, and therapists can use modifier 59 any time 2 different wound/ulcer management procedures are performed at the same encounter: ☐ True ☐ False |
| 15 | A physician/QHP debrides 10 sq cm of subcutaneous tissue from an ulcer on the right foot and 10 sq cm of muscle and fascia from an ulcer on the left leg. The correct code(s), modifier, and unit(s) to report on the claim are: A. 11042RT (1 unit) and 11043LT (1 unit) B. 11042 (20 units) C. 11043 (20 units) D. 11042 (10 units) and 11043XS (10 units) E. None of the above |
| 16 | A physician/QHP debrides 15 sq cm of devitalized epidermis and dermis and exudate from an open wound and uses chemical cauterization to achieve hemostasis. The correct code(s), modifier, and unit(s) to report on the claim are: A. 97597 (15 units) B. 97597 (1 unit) and 1725059 (1 unit) C. 97597 (15 units) and 1725059 (15 units) D. 97597 (1 unit) E. None of the above |
| 17 | A physician/QHP debrides exudate and biofilm from a 20 sq cm open wound on the left leg and debrides 10 sq cm of subcutaneous tissue from an ulcer on the left leg. The correct code(s), modifier, and unit(s) to report on the claim are: A. 97597 (1 unit) and 97598 (1 unit) B. 97597 (1 unit) and 11042XS (1 unit) C. 1042 (1 unit) and 97597XS (1 unit) D. B or C E. None of the above |
| 18 | A physical therapist debrides devitalized epidermis, dermis, and exudate from on open 50 sq cm venous ulcer. The correct code(s), modifier, and unit(s) to report on the claim are: A. 97597 (1 unit) and 97598 (1 unit) B. 97597 (1 unit) and 97598 (2 units) C. 97597 (3 units) D. 97598 (3 units) E. None of the above |
| 19 | On May 2, 2022, a physician/QHP debrides 20 sq cm of subcutaneous tissue from a venous ulcer on the left leg and then applies a multi-layer compression bandage system to the same leg. The correct code(s), modifier, and unit(s) to report on the claim are: A. 11042 (1 unit) and 2958159 (1 unit) B. 29581 (1 unit) C. 11042 (1 unit) D. 99213 (1 unit) and 29581 (1 unit) E. None of the above |
| 20 | In the office, a physician/QHP debrides exudate from a 20 sq cm diabetic foot ulcer and applies the entire piece of a 22 sq cm cellular and/or tissue-based product for skin wounds (CTP) [outdated term “skin substitute”]. The correct code(s), modifier, and unit(s) to report on the claim are: A. 97597 (1 unit) and 1527559 (1 unit) and Q4XXX (22 units) B. 97597 (20 units) and 15275 (1 unit) and Q4XXX (22 units) C. 15275 (20 units) and Q4XXX (22 units) D. 15275 (1 unit) and Q4XXX (22 units) E. None of the above |
| 21 | To provide evidence of the wound’s/ulcer’s response to any treatment, which item(s) must be documented at each visit: A. Current wound volume (length in cm, width in cm, and depth in cm) B. Presence (and extent of) or absence of obvious signs of infection C. Presence (and extent of) or absence or necrotic, devitalized, or non-viable tissue; and any other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown D. B and C E. All of the above |
| 22 | The debridement progress note should include: A. Method of debridement and exact instrument used B. Exact tissue removed, such as epidermis, dermis, subcutaneous tissue, muscle, or bone C. Wound/ulcer description before and after debridement, including length in cm, width in cm, and depth in cm, description of necrotic material present, degree of epithelialization D. All of the above E. None of the above |
| 23 | Individualized treatment plans for all wounds/ulcers that require debridement should be documented in the medical record and should address: A. Pressure reduction B. Nutritional status C. Vascular insufficiency D. Infection control E. All of the above |
| 24 | Physicians/QHPs should report 11040 and 11041 rather than 97597 and 97598. ☐ True ☐ False |
| 25 | Who will Medicare pay for 97602 Removal of devitalized tissue for wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care; per session? A. Physicians B. Qualified healthcare professionals C. Therapists D. Hospital-owned outpatient wound/ulcer management provider-based departments E. All of the above |
| 26 | Dr. Jones manages wounds/ulcers for patients in skilled nursing facilities. When the patients are in Medicare covered Part A stays and Dr. Jones debrides epidermis and dermis from open wounds, how and who should he bill? A. Bill Medicare Part B for 11042 B. Bill Medicare Part B for 97597 C. Bill the skilled nursing facility for 97597 D. Any of the above E. None of the above |
| 27 | When a physician/QHP debrides epidermis and dermis from an open wound on the right foot (97597) and subcutaneous tissue from a venous ulcer on the left leg (11042), the physician/QHP should discern between the two procedures by using the modifiers RT for the right foot and LT for the left leg. ☐ True ☐ False |
| 28 |
Because all debridement codes are assigned global surgery periods of “0” days, E/M codes are usually not medically necessary at the same encounter when debridement is performed. |
| 29 | Dr. Lewis debrides 3 ulcers. She debrides 20 sq cm of subcutaneous tissue from an ulcer on the left leg, 10 sq cm of subcutaneous from and ulcer on the right leg, and 5 sq cm of bone on the left heel. Select the correct codes to report for this work. A. 11042 (1 unit), 11045 (1 unit), and 11044XS (1 unit) B. 11042LT (1 unit), 11045RT (1 unit), and 1104459 (1 unit) C. 11042 LTRT (2 units), and 11044 (1 unit) D. 11042 (3 units) E. 11044 (3 units) |
| 30 | Because debridement procedures are not site specific, physicians and QHPs should always used unspecified diagnosis codes to describe the medical necessity for debridement: ☐ True ☐ False |
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