Don’t Cut Corners: A Thorough Review of Debridement Coding
This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.
Don’t Cut Corners: A Thorough Review of Debridement Coding
Wound debridement accounts for a major portion of wound care services billed, but the CPT codes involved are more complex than they may seem at first glance, while payers have regularly targeted these codes for review. Given the reimbursement stakes and the payer scrutiny, a review of debridement coding would be beneficial to any auditor who does work in the wound care space.
A previous NAMAS tip on wound care addressed the role of wound measurements for debridement coding (September 2016). In this tip, we will examine the CPT language governing the type of excisional debridement code used (by depth of excised tissue), and the distinction (not always clear) between excisional and selective debridement.
Determining the excisional code to use
The excisional codes are divided into three categories based on the depth of debridement. A subtle but absolutely crucial point is the meaning of this phrase, “depth of debridement.” The CPT guidelines make it clear that this refers to the depth of tissue removed, not merely depth of tissue probed or otherwise reached during the procedure. The CPT manual states that, “when performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths.”
The codes in question are:
- 11042 (subcutaneous tissue only, first 20 cm2)
- 11045 (subcutaneous tissue only, each additional 20 cm2)
- 11043 (down to muscle and/or fascia, first 20 cm2)
- 11046 (muscle/fascia, each additional 20 cm2)
- 11044 (down to bone, first 20 cm2)
- 11047 (bone, each additional 20 cm2)
Excisional vs. selective debridement
Not all debridement procedures can be reported using the excisional codes. Selective debridement is simpler from a coding standpoint and does not distinguish between the depth of tissue removed. The selective codes are:
- 97597 (may use sharp debridement,
waterjet, whirlpool, first 20 cm2)
- 97598 (selective debridement, each additional 20 cm2)
Excisional procedures have a specific purpose, namely to create a viable wound bed by removing devitalized, necrotic tissue. It refers to cutting away non-viable into viable, bleeding tissue upon which granulation tissue can form to fill the wound defect. The following breakdown is very helpful and the language cited is from “Wound Debridement, an Overview,” Podiatry Management, November/December 2012.
Excisional debridement: This type of debridement “is not expected to be performed repeatedly in a short period, in most cases, as tissues such as skin, muscle, fascia and bone cannot regrow quickly. Reasons to use this code signaling an aggressive debridement repeatedly would include cases of advancing necrosis and/or infection of a wound bed and periphery.”
Selective debridement: “This is the type of debridement that one would expect to perform on a regular basis as a part of good wound care. This debridement is not overly aggressive, but is purposeful in that the goal is to remove the obvious foreign material for a dirty, but otherwise healthy, wound bed.”
When it comes to determining whether a procedure is excisional or selective based on sometimes unclear operative notes, keep the following points in mind. These are not individually decisive, but combined with the above descriptions of the purpose for excisional and selective debridement, should help you determine which set of codes to use.
- Excisional debridement: Surgical removal of necrotic or devitalized tissue that, at a minimum, continues until healthy, viable, bleeding tissue is encountered.
- Wound size is increased
- Some viable tissue is removed
- Bleeding almost always occurs unless patient has vascular issues, which should be documented
- Anesthesia is almost always used
- Sharp instrument is always used
- Selective debridement: Surgical OR non-surgical removal of necrotic or non-viable tissue that is usually superficial and does not enter healthy, viable tissue.
- Wound size remains the same or increases only slightly
- No viable tissue is removed
- Bleeding is minimal or non-existent
- Anesthesia is not always used if only dead tissue is being cleaned off
- Wide variety of instruments and tools can be used
Other warning signs for auditors to notice when it comes to determining whether excisional or selective codes are supported include the provider’s billing pattern and documentation tendencies. For example, is the provider constantly billing excisional services and rarely billing selective services for the same patient? We would expect the reverse ratio to be true as excisional services are not repeatedly performed in a short time for the same patient. Also, is the provider using the same operative note language in every note? Finally, keep in mind that the language matters when it comes to describing the type of tissue removed. Excisional debridement removes necrotic, contaminated, or infected tissue. Selective debridement covers a much wider variety of tissue, including non-viable but far less harmful material such as callus tissue, debris, biofilm, and fibrin (though it may also include removal of devitalized tissue though typically not in the amounts associated with an excisional procedure).
This Week’s Audit Tip Written By:
Grant is a compliance consultant at DoctorsManagement, LLC, and director of content for NAMAS.
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