Current Topics in Billing and Coding: Surgical Debridement
- Thu, 10/15/09 - 9:58am
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The subject of this article is surgical wound debridement performed by physicians. Surgical debridement is an important component of chronic wound treatment, and has been described by one author (along with systemic antibiotic therapy and strict measures to reduce weight bearing) as a “cornerstone of effective wound care.” Debridement is the process of removing de-vitalized tissue and foreign matter from a wound bed. Because devitalized tissue can impede the healing process, physicians often choose to debride a wound bed as part of the wound treatment process. Four methods of debridement exist:
3) enzymatic, and
This article focuses on surgical debridement.
Although there are a variety of CPT codes that describe debridement procedures, surgical wound debridement procedures are primarily coded in outpatient settings with CPT codes 11040-11044. The particular codes reported depend upon the types of tissues debrided, eg:
• 11040 (Debridement; skin, partial thickness);
• 11041 (Debridement; skin, full thickness);
• 11042 (Debridement; skin, and subcutaneous tissue);
• 11043 (Debridement; skin, subcutaneous tissue, and muscle); and
• 11044 (Debridement; skin, subcutaneous tissue, muscle, and bone).
These codes should not be confused with the active wound care management codes (97597-97602), which are usually reported by non-physicians for selective and nonselective debridement procedures, and are not to be reported with codes 11040-11044. Further explanation of the differences between these two code sets is available in Principles of CPT Coding 4th Edition by the American Medical Association.
Several points need to be highlighted regarding the surgical debridement code set 11040-11044:
The global period for 11040-42 is zero and 11043-44 is 10 days, meaning that all the pre-service, intra-service, and post-service work (up to 10 days for 11043-44) and cost to provide the service are included in the code:
• CPT guidelines do not restrict the number of times that the debridement codes can be reported for a course of treatment;
• Debridement codes may only
be billed once per lesion per debridement session;
• To report debridement of multiple sites (wounds), CPT codes 11040-11044 may be used more than one time in a single patient encounter. The appropriate code is selected for each site depending on the type of debridement performed, and the -59 modifier (distinct procedural service) is appended to
the secondary (and tertiary, if applicable) code.
These attributes of the 11040-11044 code set mean that the surgeon is not restricted as to when to report debridement. Below we discuss some of the legal issues that can arise with respect to debridement services.
II. Surgical Debridement and Medicare Requirements
In 2007, the Department of Health and Human Services Office of the Inspector General (OIG) issued a report titled Medicare Payments for Surgical Debridement Services in 2004. The OIG found that “Medicare allowed approximately 188 million in 2004 for surgical debridement services, [but that] [a]n estimated 64 percent of these services did not meet one or more Medicare program requirements.” The OIG recommended that CMS “strengthen program safeguards to prevent improper payments for surgical debridement services.”
In response to this report and reflecting ongoing efforts by CMS and its contractors to improve program integrity, local coverage determinations (LCDs) for surgical debridement have proliferated with specific coding guidance and requirements for medical record documentation as to whether debridement is medically necessary. Therefore, it is necessary that physicians fully understand all of the requirements imposed by their local Medicare Administrative Contractor (MAC) in LCDs and develop a system for consistently documenting what is necessary to satisfy each and every requirement. Physicians should expect that MACs will perform audits on claims for debridement as well as more extensive reviews of outlier physicians or clinics. If the result of such a review indicates that the medical record did not support medical necessity, then the MAC can institute corrective action, which can take one or more of several forms depending on the error rate. The actions a MAC can take include; provider education, request recoupment for the services reviewed, perform a more extensive claims review that can result in recoupment based on extrapolation, institute prepayment review and refer the provider to the fraud unit or the Department of Justice.
The three key issues that must be included in the medical record documentation are:
(1) demonstrating/supporting the medical necessity for performing debridement,
(2) showing that the extent of the debridement performed matches the CPT code that was reported, and
(3) showing progressive improvement with debridement over time.
1. Sumpio BE. Foot Ulcers. New Engl J Med 2000;343:787-793. 2. Medicare Payments for Surgical Debridement Services in 2004, May 2007, available at http://oig.hhs.gov/oei/reports/oei-02-05-00390.pdf. 3. See OIG Compliance Program for Individual and Small Group Physician Practices available at http://www.oig.hhs.gov/authorities/docs/physician.pdf.