Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay forsurgical wound preparation (15004). We decided that the Plan does not have to pay fordebridement (11042). You asked the Plan to pay forsurgical wound preparation (15004). You say that these services are supported by the record.The Plan says that the operative report does not document these services.We decided that the Planhas to pay forsurgical wound preparation (15004). The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 15004 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children .We asked our physician reviewer to carefully review the case file andapply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for surgical wound preparation. Our reviewer says that CPT 15004 is supported by the records. Our physician reviewer found the procedure performed was selective debridement of ulceration of the left: 6 cm? of debridement performed using a 10 blade, in preparation for a fresh amniotic graft Artacent. All nonviable tissue was removed from the wound bed and the ulceration was irrigated with normal saline priorto the application of the graft. The documentation does support CPT 15004, Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar. There is documentation of excision of the enrollee's open wound in preparing the site to receive the graft. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical wound preparation have been met.Therefore, we decided that the Plan has to pay forsurgical wound preparation (15004). We also decided that the Plandoes not have to pay fordebridement (11042).The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 11042 is debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for debridement. Our reviewer says that CPT 11042is not supported by the records. Our physician reviewer found that CPT code 11042 would be considered inclusive to CPT code 15004, and would not be covered separately.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of debridement(11042)have not been met.Therefore, we decided that the Plan does not have to pay fordebridement (11042)