Do Not Report a Code If You Do Not Know the Rules

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In last quarter’s Consultation Corner, we discussed the importance of setting up your revenue cycle process correctly to prevent claim denials, post-payment audits, and repayments. Unfortunately, some wound/ulcer management professionals are either not reading reimbursement guidance books and documents or are not aligning their processes with the published rules.
In this quarter alone, I consulted with 50+ professionals, providers, and suppliers who were paid by Medicare, but failed post-payment audits. In most instances, the stakeholders could have prevented the repayments. A perfect example is a consultation that I just completed. Don’t let this happen to you!

Real-Life Scenario:

A group of physicians, podiatrists, and nurse practitioners added wound/ulcer management to their office practice during the COVID-19 public health emergency (PHE). Because the local hospital owned outpatient wound/ulcer management provider-based department was closed during the PHE, their office practice rapidly grew.

Unfortunately, their office practice just completed a Medicare post-payment audit, focused on debridement, which resulted in a large repayment. They contacted me to help them understand what went wrong and to educate them on how to pass future audits.

Facts to Consider:

• The A/B Medicare Administrative Contractor (MAC) for each Jurisdiction processes Medicare claims for office practices.
• Wound/ulcer management professionals use both Current Procedural Terminology® (CPT®) codes and Healthcare Professional Coding System (HCPCS) codes to report the services, procedures, and products performed in their offices.
• Every year, the American Medical Association (AMA) updates and publishes its CPT codes, descriptions, and instructions in the Current Procedural Terminology® codebook.
• The Centers for Medicare & Medicaid Services (CMS) update the HCPCS codes for drugs and biologics 4 times per year and for non-drugs and biologics twice per year. CMS publishes all the HCPCS codes on its website.
• The A/B MACs provide a myriad of readily available educational resources that pertain to debridement and to the other services, procedures, and products that wound/ulcer management professionals provide to Medicare beneficiaries.

Findings From the Debridement Audit

I reviewed the auditor’s report with the results of the debridement audit and quickly understood why the office practice was selected for the audit. The physicians, podiatrists, and nurse practitioners did not follow the CPT® code descriptions, instructions, and regulations pertinent to the various levels of debridement. The main errors were:

1.    They did not select debridement codes based on the type of tissue removed.
2.    They reported a separate debridement code for each ulcer that was debrided, even if they debrided the same type of tissue from each ulcer.
3.    Regardless of the level of tissue removed, they always reported the code for debridement of muscle and/or fascia (11043).
4.    They never reported the codes for debridement of subcutaneous tissue (11042) or for debridement of an open wound (97597).
5.    If they provided conservative care and/or debrided ulcers for 4 weeks, and the ulcers did not show signs of healing, they debrided the ulcers a fifth time and reported the surgical preparation code 15002. At the same encounter, they applied a cellular and/or tissue-based product (CTP) for skin wounds and reported the code for the CTP application and the code for the CTP product.

Consultation About the Debridement Audit

I began the consultation by asking the team of professionals to retrieve the CPT code book that they are using this year. They looked at each other and asked if anyone had a CPT code book. To my surprise, no one had a 2024 CPT code book, or a CPT code book from any prior year. I then asked them how they knew which codes to bill. They told me they met a physician at a wound care symposium. He told them the best codes to report to maximize their revenue. That explained why they incurred such a large repayment for the debridements that they reported and charged to Medicare.

Luckily, I packed my 2024 CPT codebook and brought it to their office. First, I showed the team the 6 debridement codes in the surgical section of the CPT codebook. After they read the code descriptions, they agreed that they rarely removed muscle, which is what they coded at every encounter. In fact, they said they typically only removed subcutaneous tissue at the first debridement, which they learned should be coded as 11042. When asked what type of tissue they debride after the first debridement, they replied that they typically debride fibrin, exudate, or biofilm. I then showed them the 2 CPT codes for debridement of an open wound, 97597 and 97598. The team agreed that those 2 code descriptions best describe the type of tissue that was debrided during those encounters.

All the professionals then understood that they had not correctly reported their debridement work. As expected, they quickly wanted to know the 2024 Medicare allowable payment rates for the 6 surgical debridement codes and for the 2 debridement of open wound codes. After I shared their 2024 Medicare allowable rates for the 8 codes, they complained that reporting the correct codes would not pay as much as their payment for 11043. Their complaining stopped when I reminded them that after the audit, they did not get to keep the money they were paid for most of the debridement procedures reported with 11043.

Once the team understood how to select the debridement codes based on the code descriptions, I then showed them that the CPT codebook also provides debridement coding rules:

• 11042–11047 should be reported for injuries, infections, wounds, and chronic ulcers.
• 11042–11047 should be reported based on the deepest level of tissue removed (subcutaneous tissue, muscle/fascia or bone) and the surface area size of the wound(s)
• 97597–97598 should be reported when fibrin, devitalized epidermis and/or dermis, exudate, debris, or biofilm are removed from an open wound.
• At the same encounter, when the same level of tissue is debrided from multiple wounds, sum the debrided surface area of all those wounds.
• At the same encounter, when various levels of tissue are debrided from multiple wounds, report the appropriate debridement codes that describe each level of tissue debrided and the surface area size of the wound(s).

Then I turned the team’s attention to the code descriptions and coding rules for surgical preparation or creation of the recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissue) (15002–15005). The rules in the CPT codebook state that one should remove an appreciable amount of nonviable tissue to treat a burn, traumatic wound, or a necrotizing infection, and that 15002–15005 should not be reported for removal of nonviable tissue/debris in a chronic wound such as a venous or diabetic ulcer left to heal by secondary intention. At that point, the team members concurred that the debridement they perform before they apply CTPs does not align with the code description and coding rules for 15002–15005.
 
After discussing the correct debridement codes and code selection rules, I asked the team if their MAC released an LCD and LCA that provided coverage criteria for utilization and frequency of debridement. Because they did not know, I showed them how to search their MAC’s coverage database for pertinent LCDs and LCAs. The team was amazed at the level of debridement coverage and coding guidance included in the LCDs and LCAs. In fact, they had no idea that their MAC, like all other MACs, expected them to use the operative note format for the surgical debridement documentation, and for all codes in the surgical section of the CPT codebook. While visiting their MAC’s website, I showed them how to search for other guidance documents pertaining to debridement. We found an excellent debridement documentation checklist they could use to improve their documentation and their electronic health record template. They were also surprised to learn that the auditor used their MAC’s LCD and LCA, as well as the debridement documentation checklist, to perform the debridement audit that resulted in repayment.
 
Finally, I explained that all MACs are evaluated on the accuracy of their claim processing. Therefore, they have a personal stake in educating the professionals in their jurisdiction. I showed the team members where to find the myriad of educational opportunities that their MAC sponsors each year. The team members were amazed at the number of debridement education offerings we found: live and recorded webinars, newsletters, self-paced training courses, an instructional booklet, the documentation checklist, live question and answer sessions, You Tube videos, findings of debridement audits performed, and even the opportunity to request one-on-one education classes tailored to meet the professionals’ needs. By the time we perused all the education that their MAC offers, every member of the team was enthusiastic to take advantage of their MAC’s educational resources that pertained to the major services, procedures, and products used in their wound/ulcer management business. Most important, they learned the importance of knowing the coding rules before reporting codes. They also learned they should select the code that accurately describes the work they perform, not the code with the highest payment rate.

Summary:

This consultation was one of many where this author/consultant identified that wound/ulcer management professionals tend to pass incorrect reimbursement information to each other. The MACs and I go out of our way to educate professionals about appropriate codes, coding rules, coverage guidelines, documentation, and payment.
 
I am always sad when the outcome of a client’s failed audit is the stimulus to improve their business processes. Therefore, I hope that all readers will be motivated to learn the right way to document, code, and receive payment for the impressive work you perform. You can start your ongoing learning by signing up for your MAC’s email list. That way, you will receive all the MAC’s revenue cycle information and notices of all the educational opportunities that they provide. In case you do not know where to sign up for your MAC’s email list, following are the links for all the MACs’ websites. Once you reach their homepage, scroll to words such as Email Updates or electronic mailing list, and click the SUBSCRIBE button. You will be glad you subscribed!
 
DME MACs:
CGS Administrators, LLC
Noridian Healthcare Solutions, LLC
           
A/B MACs:
CGS Administrators, LLC
First Coast Service Options, Inc.
National Government Services, Inc.
Noridian Healthcare Solutions, LLC         
Novitas Solution, Inc.
Palmetto GBA, LLC
Wisconsin Physicians Service Government Health Administration
                       
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@gmail.com.