Do Not Limit Where Ulcer Debridements Can Be Performed!

Medicare is a national program administered on a local level by Medicare Administrative Contractors (MACs). At the time of this writing, there are 8 MACs in the United States. The MACs can choose to issue Local Coverage Determinations (LCDs) to offer guidance and requirements regarding coding, documentation, and compliance for certain procedures. Of the 8 MACs, 7 have LCDs regarding debridement of chronic ulcers; some of which have a restriction that will not allow payment for debridement services to the depth of muscle/fascia (Current Procedural Terminology [CPT] 11043) and/or bone (CPT 11044)¹ if they are performed in an office setting. Limiting the place of service for these debridements is not only detrimental to all involved but impractical as well. 

A MAC limiting where debridements to the depth of muscle/fascia and/or bone can be performed goes against guidance provided by Medicare itself. Medicare Learning Network Matters article MM782 explains that some services are assigned 2 different payment amounts.² One of these amounts is for when the service is performed in a facility and the other for when that same service is performed in a non-facility such as a physician’s office. Some services do not have a non-facility value assigned, which limits the performance of the service to facilities only. However, with regard to the 2 CPT codes in question, there are non-facility fees assigned by Medicare to CPTs 11043 and 11044. It does not make sense for Medicare to assign a non-facility fee to a service then have a MAC declare that that same service cannot be performed in a non-facility.

Another reason preventing payment for ulcer debridements in the office setting is impractical is that it actually ends up resulting in higher costs to the MAC. It is much more expensive to do a procedure in an operating room versus in an office. This results in unnecessary costs to the payer, the health care system, and potentially the patient. 

If safety is a concern, consider some procedures that are allowed to be performed in an office setting. The same MACs that will not allow payment of CPT 11043 and/or CPT 11044 if performed in an office do permit payment for a bunionectomy performed in an office. A bunionectomy involves dissection down to the muscle/fascia and cutting of bone. If safety is their concern, why allow exposure of the same layer of tissue for one procedure but not another in the same setting? 

Most importantly, limiting the place of service for ulcer debridement can negatively impact the patient that is suffering with the ulcer. A chronic ulcer is often a life-threatening situation.³ The literature demonstrates the importance of sharp debridement in treating chronic ulcers.⁴ If a patient is seen in an office that requires ulcer debridement to the level of muscle/fascia in a state with a LCD that does not allow payment for that service performed in the office, the patient may have to wait to receive this service until it can be scheduled in a facility. This delay can have a negative impact on the patient’s outcome, which is unacceptable for everyone.

These are just a few reasons why it is not appropriate for a MAC to forbid payment for ulcer debridement to the depth of muscle/fascia and/or bone in an office setting. Advocacy on the part of all involved in wound care can help to address this problem. Medical directors at these MACs can be educated with the type of information listed herein. This can come from patients, providers, wound care societies, and stakeholder alliances. 

Affiliation: Lehrman Consulting, LLC

Correspondence: Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, Lehrman Consulting, LLC; DoctorLehrman@gmail.com 

Disclosure: The author discloses no financial or other conflicts of interest.