Getting Paid in the Outpatient Center for Ulcer Debridement

Accurate coding is essential to protect your practice and manage risk. This author takes a look at the correct AMA CPT and ICD-10 codes to use so your wound clinic can remain compliant.

When coding and documenting, it is important to remember that a wound and an ulcer are two different things, despite the fact that some clinicians use the terms interchangeably. A wound is typically due to trauma while an ulcer is chronic. There are differences in coding and documentation when dealing with wounds and ulcers.

When coding for ulcer debridement, the code is selected based on the deepest depth of tissue removed, not the depth of the ulcer. Furthermore, the total square centimeters of tissue removed factors into code selection. The location of the ulcer plays no role in code selection and neither does the place of service.

The AMA Current Procedural Terminology (CPT®) codes 11040 and 11041 have been deleted.1 They should never be used. As of 2011, these codes have been replaced by 97597 and 97598.

CPT 97597 is for the debridement of an ulcer to the level of epidermis/dermis if the total sq cm of tissue removed is less than or equal to 20 sq cm. When using this code, remember to calculate the total sq cm of tissue removed, which can encompass more than one wound. If you debride more then 20 sq cm total, use CPT 97598 as an add-on code with CPT 97597. Never use CPT 97598 alone. The CPT 51 modifier should never be appended to CPT 97598.

CPT 11042 is for debridement to the depth of subcutaneous tissue, first 20 sq cm or less total. CPT 11045 is an add-on code for each additional 20 sq cm of subcutaneous tissue removed.  

CPT 11043 is for debridement to the depth of muscle/fascia, first 20 sq cm or less total. CPT 11046 is an add-on code for each additional 20 sq cm of muscle/fascia removed.

CPT 11044 is for debridement to the depth of bone, first 20 sq cm or less total. CPT 11047 is an add-on code for each additional 20 sq cm of bone removed.  

When cellular and/or tissue based products for wounds (CTPs) are used in the outpatient setting, there are CPT codes for application and Q codes for the product. In certain settings and for all products except one, the application and the product may be bundled into one code. 

As for diagnosis coding options for ulcers, use L97- (non-pressure chronic ulcer of lower limb, not elsewhere classified) for diabetic foot ulcers. Any foot ulcer on a patient with diabetes, regardless of cause, is considered a diabetic foot ulcer.

For L97-, fourth character options (mandated by the hyphen) include 1 (thigh), 2 (calf), 3 (ankle), 4 (midfoot and heel), 5 (other part of foot), 8 (other part of lower leg) and 9 (unspecified part of lower leg). The fifth character options include 0 (unspecified), 1 (right) and 2 (left). Sixth character options include 1 (limited to breakdown of skin), 2 (with fat layer exposed), 3 (with necrosis of muscle), 4 (with necrosis of bone), 5 (with muscle involvement without evidence of necrosis), 6 (with bone involvement without evidence of necrosis), 8 (with other specified severity) and 9 (with unspecified severity).

L89- is for pressure ulcers/injuries. Fourth character options (mandated by the hyphen) include 0 (elbow), 1 (back), 2 (hip), 3 (buttock), 4 (contiguous site of back, buttock and hip), 5 (ankle), 6 (heel), 8 (other site) and 9 (unspecified site). The fifth character options include 0 (unspecified), 1 (right) or 2 (left). Sixth character options include 0 (unstageable), 1 (Stage 1), 2 (stage 2), 3 (Stage 3), 4 (Stage 4), 6 (deep tissue damage, effective Oct. 1, 2019) and 9 (unspecified stage).

I look forward to discussing the documentation requirements and compliance guidelines that surround ulcer debridement in one of my talks at SAWC Spring in May 2020 in San Diego.

Dr. Lehrman is a Certified Professional Coder and an Advisor to the American Podiatric Medical Association (APMA) Coding Committee. He is an Expert Panelist for Codingline. He is an Advisor for the APMA MACRA Task Force and a Fellow of the American Academy of Podiatric Practice Management. Dr. Lehrman is a member of the Board of Directors of the American Society of Podiatric Surgeons and the Board of Directors of the American Professional Wound Care Association. He is on the Editorial Advisory Board of WOUNDS.

This was curated by WCLN editor, Brian McCurdy.

Reference

1. Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2019 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA). Applicable FARS/DFARS apply.

Disclaimer: CPT codes and their descriptions do not reflect or guarantee coverage or payment. Just because a CPT code exists, payment for the service it describes is not guaranteed. Coverage and payment policies of governmental and private payers vary from time to time and for different areas of the country. Questions regarding coverage and payment by a payer should be directed to that payer.