Cath Lab Digest

  In 2007, TWC published an issue on debridement, which included a “test” for clinicians to help them assess their ability to properly code these procedures. Kathleen Schaum, Dot Weir and I worked hard on that issue and found that despite the fact we thought we knew the topic very well, the complexities of the system made it a challenging issue to write. Debridement coding is about to get even more complicated. In January 2011, coding for wound debridement will change significantly. Kathleen Schaum’s Business Briefs article explains the specific coding changes. The goal of this article is to provide clinical context for using these revised/new debridement codes.

  Some background information may be useful to understand what led to these changes. In May 2007, the Office of the Inspector General (OIG) released a report on Medicare Payments for Debridement Services in 2004 (OEI 02-05-00390). The OIG had seen a dramatic increase in the number of Medicare claims submitted for the surgical debridement of wounds under CPT® codes 11040–11044. In 2004, Medicare paid out $188 million for surgical debridement services. However, as much as 64% of surgical debridement services that year did not meet Medicare program requirements. They determined that this resulted in $64 million dollars of improper payments. A variety of problems were noted such as the fact that 47% of miscoded services were not actually surgical debridements. For example 20% were actually routine foot care (eg, removal of a corn or callus) that should not have been billed as a surgical debridement. Then there were documentation problems.

  Specifically, 29% of surgical debridements were either not documented at all or insufficiently documented to justify the billed service. Most concerning were the observations that “some of these services might have been part of an inappropriate pattern.” For example, one patient had 43 debridements involving muscle within a 9-month period. Presumably, the recent changes in billing codes represent The American Medical Association’s (AMA) response to the way in which surgical debridement codes have been used (and perhaps abused) in the past. There is no argument that debridement remains an important part of chronic wound care. The nonviable material within a chronic wound has been shown to inhibit the development of granulation tissue, enhance bacterial growth and decrease resistance to infection. Different procedures of varying complexity may be required to accomplish adequate debridement. In some cases, only superficial slough needs removing. In other cases, the tissue requiring removal may include necrotic bone. This means that in some situations, debridement is a surgical procedure performed by a trained individual with a scalpel and requiring analgesia, and in other cases can be accomplished with a water pick or even with the right choice of dressing.

Types of Debridement: Clinical vs. Coding and Payment

  From a clinical standpoint, debridement techniques have not changed. However, there is a disconnect between the way we think, speak, and document about debridement clinically, the way it has historically been coded in the past, and will be coded in the future.

  From a clinical standpoint, debridement has been divided into the
following categories:
    1. Surgical and non-surgical “sharp” debridement describes the use of instruments such as scissors, scalpels or curettes to remove tissue. Clinically, these may require anesthesia and/or the control of bleeding, and must be performed by a qualified professional.
    2. Mechanical debridement may include the use of wet-to-dry gauze dressings, water jet or ultrasonic irrigation.
    3. Autolytic debridement is the process by which the wound bed clears itself of devitalized tissue using phagocytic cells and proteolytic
enzymes (the body’s own natural enzymes) to liquefy necrotic tissue. This is accomplished by keeping the wound moist with occlusive or semiocclusive dressings.
    4. Chemical debridement is the application of topical agents that disrupt or digest extracellular proteins. An example is the enzyme collagenase, derived from the fermentation of Clostridium histolyticum.
    5. Maggots represent a form of biological debridement which is relatively painless and specific to necrotic material. (I am personally big fan of maggots, particularly for inflammatory ulcers, which may exhibit pathergy if sharp debridement is used, but reimbursement is an issue. See the Clinician report in this issue for more details.)

  I will interject a comment about the code “97602” which is, “Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia.” This code has not changed from 2010 and continues to be used for wet-to-moist dressing debridement, enzymatic debridement, and debridement by abrasion, etc. in 2011.

  Medicare contractors do not reimburse physicians for this code but they do reimburse the Hospital-based outpatient wound care department (HOPD) for this work. However, just because an occlusive dressing is used does not mean that you SHOULD bill this code. I frequently hear of wound centers which either will not use certain dressing products (eg, hydrocolloids or even hydrogels) because they feel they MUST bill 97602 if they do so, or which always bill 97602 if certain dressing products are used. This is a broad over-reading of this code. If an occlusive dressing is not used specifically for the purpose of debridement, you should bill an evaluation/management code for this visit.