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The Debridement Dilemma Returns

  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.

  From a coding and payment standpoint, in the past much attention has been given to the terms “selective” and “non-selective” and “sharp” and/or “exicisional.” In general, debridement techniques, which were under the direct control of the clinician, were viewed as “selective” (eg, holding a scalpel) whereas if a bandage or an enzymatic agent performed the debridement (instead of the clinician), it was viewed as “non-selective.” While the term “selective” still appears in the coding language for 97597 and 97598, the importance of this word has diminished as a result of the changes in the codes discussed below. It is important to note that these new codes represent a subtle change in the meaning of the word “sharp.” We used to take the word “sharp” to be synonymous with “scalpel” but the new coding descriptions make it clear that scissors and other tools might be used. The best advice is for clinicians to refrain from the term “sharp debridement” and clearly state the way in which they performed the debridement, including the specific tools used. For 97597/97598, you must state the method used (since it can be high pressure water jet with or without suction, sharp selective debridement with scissors, scalpel, and forceps). For 97602, you must state the method used to remove the devitalized tissue. For 11042-11047, the physician must state the type of instrument that was used to debride the tissue.

  As Kathleen Schaum explains in Business Briefs, the CPT® Codes 11040-11041 for “Surgical Exicisional Debridement” of partial and full thickness skin, have been deleted effective January 1, 2011. Providers should now use codes 97597 and 97598. These are not new codes; they are existing codes whose meaning has changed. The code “97598”, which used to be a “primary code,” is now an “add-on” code denoting each additional 20 cm2 debridement size. The first thing to emphasize is that these codes pertain to the debridement of a wound. If you debride necrotic debris or skin and find that no wound is present, then you cannot use these codes. A physician asked me this week, “What if I debride a callous and there is no wound underneath? In that case you have done a callous paring, there is no open wound and these debridement codes do not apply. “Routine foot care” is one of the scenarios in which the OIG cited as a misuse of the debridement codes.

  I have struggled with the way the codes 97597 and 97598 replace 11040 and 11041.The wording of this code is “Debridement (eg, … sharp selective debridement …), open wound, (e.g. …devitalized [CF italics], epidermis and/or dermis …) …”

  In the past when I debrided full thickness viable skin I would have used the code 11041because the code 11042 was not to be used unless the debridement extended into the subcutaneous tissue. Now if I do not debride subcutaneous tissue, but only debride viable full thickness skin, what code am I to use? The CPT “crosswalk” instructions tell me to use the codes 97597/97598, even though the specific description of that code says it is the debridement of non-viable skin. So, from a clinical standpoint, the CPT® description of 97597/97598 does not really describe the process of debriding full thickness viable skin, but there is no longer a code specifically for this process. The codes 97597/97598 are to be used for the debridement of any tissue which does not involve subcutaneous tissue, muscle, or bone. In some ways this may make coding easier.

  There seemed to be a lot of confusion in the proper use of codes 11040 and 11041. It may be easier for clinicians to remember that debridement of any material, from slough and debris to full thickness skin, is now encompassed by 97597 and 97598.

  Perhaps the most important thing to emphasize clinically is an issue which has not changed. The debridement code chosen must be based on the type of tissue removed, and not the tissue exposed after debridement or the grade of wound. The use of the codes 11042, 11043 and 11044 are unchanged from the standpoint of the depth of tissue they represent. They are to be used whenever subcutaneous tissue, muscle or bone are debrided. The challenge comes in correctly using the new “add-on” codes for the additional surface area.

Test Yourself

  I tried to understand these changes by reading the coding verbiage and it was very difficult. The only way I could work through this complex process was to take actual patient wound measurements and practice coding the procedures. I have provided some of examples in a Power Point posted on the TWC website at http://todayswoundclinic.com/intellicure-debridement-twc. More information is available at the following website http: www.Intellicure.com/CodingHelp.

  This new system dramatically increases the importance of accurate wound measurements. There are a variety of techniques for wound measurement including longest length x widest width, but it may also be done using the head to toe measurement and taking the width perpendicular to this. These two methods can provide quite different results depending on how irregular the wound perimeter is. There is no universally accepted method for wound surface area calculation and CMS offers no guidance on this matter. Surface area is normally calculated by multiplying length x width. However, this two-dimensional method assumes that the wound’s geometry resembles a rectangle. Wounds may be more likely to resemble a circle or an oval. While relatively simple calculations could be used to accommodate these other shapes, the most common practice for calculating surface area is the simple “length x width.” There are several automated measuring tools, some incorporated in cameras, which may allow precise surface area measurements to be automated inexpensively in the near future.

  Despite the dependence of the new codes on measurements, the AMA and the Medicare contractors have provided no particular guidance on measurement technique (other than measurements must be in centimeters). However, the debridement of a 20.1 cm2 wound would be billed at a higher rate than a 20.0 cm2 wound. Given the considerable variability of wound measurements even among the most careful clinicians, it seems likely that the new codes will encourage measurement techniques which maximize surface area calculations. The new system also creates challenges for highly irregular wounds. As long as the total surface area is less than 20 cm2, these individual measurements may not be important, but once the cumulative measurement exceeds 20cm2, the billing implications can be
significant.

How Much Will These Changes Really Affect Your Billing?

  We reviewed data from the U.S. Wound Registry managed by Intellicure which contains data from 725,000 wound/visits (encounters in which wounds were measured). We found that 84% of wound visits have surface area measurements less than 20 cm2. Therefore, most debridement charges will require only the primary code. According to registry data, the “add-on” codes will be needed in only one in ten debridements. However, when wounds do measure more than 20 cm2, the average area is a surprising 79 cm2. In other words, the majority of wounds seen in hospital based outpatient wound centers are small, but when they are not small, they are very large. So, when an “add-on” code is used, you will likely bill it in multiples.

Questions Without Answers:

  There are some questions I have about implementing these new codes for which I do not have answers. One of the biggest questions has to do with undermining. I recently saw a patient who had developed a very large Methicillin resistant staph abscess on her anterior leg. There were several small wounds over the shin whose total wound surface area was less than 20 cm2. However, all these wounds undermined extensively and in fact connected together in the deep subcutaneous fat. After debridement the surface area of the one wound was more than 15 cm x 10 cm (150 cm2), several times larger than the sum of all the pre-debridement wounds. It does not appear that undermining can be used in the calculation of wound surface area. There is also no guidance as to whether we are to use pre- or post-debridement measurements, for calculating billing, but the post debridement measurement would seem the most accurate. (Take special note of Kathleen Schaum’s analysis of the various Medicare contractors’ Local Coverage Determination’s (LCD) verbiage. Some mandate post-debridement measurements but do not say which measurements are to be used for coding.)

  Another question is, “What if only part of the wound needs debridement?”
I recently saw a patient with a very large ulcer involving almost her entire calf, but only about 30% of the ulcer required debridement of an eschar, the rest was beginning to granulate. I had to debride the eschar and clean and dress the entire wound surface area. At this time, the verbiage in the debridement codes says that coding is based on the surface area of the ulcer (and the type of tissue debrided), not the area debrided. Some providers believe they are to code only the portion of the wound that is debrided. When I bill this procedure using the 2011 codes, based on the size of the ulcer, I believe that I should bill for the larger wound surface area that I managed, not just the size of the debrided portion of the wound. Hopefully the American Medical Association will provide some clear guidelines to these questions and many other questions that will no doubt arise as we attempt to implement these debridement code changes.

What Hasn’t Changed: The Importance of Documentation

  A major concern expressed by the OIG in their 2007 report was that debridement documentation was inadequate to determine whether the services were either medically necessary or coded accurately. The provider must state exactly “what” and “why” the work is being done; properly document the type of tissue that was debrided; the depth of the debridement; the device, drug, or dressing that was used for the debridement; the size of the wound before and after the debridement; and the condition of the wound after the excision or debridement.

  The specific documentation necessary differs somewhat according to your Medicare contractor’s LCDs and you are advised to become familiar with your own regional LCDs. Pay special attention to Kathleen’s incredibly helpful chart noting the different requirements of the various LCDs! Note that some specifically require post debridement measurements. LCDs usually require that debridement notes document (at a minimum) the following:

    1. Describe the medical condition, including current treatment diagnosis and all relevant diagnoses, of the patient.
    2. Describe the wound sufficiently to document medical necessity for the service, including the size and depth of the wound.
    3. Document the presence and extent of or absence of signs of infection and/or the presence and extent or absence of necrotic,
devitalized, or non-viable tissue.
    4. Describe the method of debridement (say what “tool you used!)
    5. Include the depth (of tissue) and level of debridement or type of wound care to support the CPT code billed.
    6. Describe all dressings and/or treatments.
    7. Document the progress of the wound, including factors that would complicate normal healing, and the response of the wound to treatment.
    8. Document the total wound surface area (of all the wounds) in square centimeters.

  If you are getting the idea that the note for even a relatively simple debridement will be long and detailed, you are correct. If you are a physician who still dictates his or her procedure notes, you are going to need a list to remember all these points. Failure to document even one of them might result in a determination that the service was not medically necessary.

Global Periods and Limits on Total Number of Debridements

  The “10-Day Global Period” is the day of surgery and post operative care the patient receives after a surgical procedure, during which time the provider cannot bill another service, such as an E/M visit, without a modifier. Previously, there was a 10-day global period for the top level surgical excisional debridements (11043, 11044). Under the new Medicare Physician Fee Schedule guidelines, 11043 and 11044 now have A ZERO-DAY GLOBAL PERIOD. This means only additional services performed on the day of the debridement require a modifier.

  Some Medicare Administrative Contractors (MACs) and Fiscal
Intermediaries (FIs) have policies limiting the number of high level surgical debridements per year on a “wound” (11043 and 11044). Although the new codes do change billing so that it is no longer per “wound” but by depth and total surface area, limits on total NUMBER of high-level debridements per year may still apply. However, it may take longer to reach those debridement “maximums” since the vast majority of chronic ulcers are rather small. Even if the average patient has two ulcers, both could likely be debrided without exceeding 20 cm2. Thus, it is likely that more individual debridement “events” may occur on ulcers without those events being translated to billed “procedures” since these activities will not be billed “by the ulcer.”

Final Thoughts

These new codes are a particular challenge because the meaning of some old codes has changed, some codes have been deleted, and new codes have been created which link to old codes. It will be particularly challenging to implement these codes because the surface areas of several small wounds may be added together and billed with one debridement code. Conversely, the debridement of one very large wound could require multiple debridement codes. Clinicians must be careful to document both the type of tissue removed (not what is visible afterwards) and the size of the wound(s) in which this/these procedure(s) was/were performed. The clinician must clearly document the type of debridement that was performed. It is more important than ever to document wound SIZE (surface area) in square centimeters. (Clinicians who have been using millimeters need to stop doing that.)

  Wound care professionals should perform whichever debridement technique is most appropriate based on the needs of the wound. The frequency of debridement must also be based on the needs of the wound and should not be determined by arbitrary protocols (eg, based on calendar days or number of clinic visits). Although the examples on the website are not meant to serve as medical advice or substitute for the advice of a professional coder, we hope they will provide some “practice scenarios” to help put the revised/new debridement codes in context.

*CPT is a registered trademark of the American Medical Association.

Caroline Fife, MD, FAAFP, CWS is currently co-editor of Today’s Wound
Clinic. She is also the director of Clinical Research at the Memorial
Herman center for Wound Healing, Houston, Tex., and Chief Medical
Officer of Intellicure, Inc. She can be reached at
cfife@intellicure.com.

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Feature Article
Caroline E. Fife, MD, FAAFP, CWS
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