Billing and Coding: Debridement Services

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Debridement Services.

**Coding Information:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.  
  
For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.  
  
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.  
  
The diagnosis code(s) must best describe the patient's condition for which the
service was performed.

**Specific Coding Guidelines:**  

CPT codes 11000 and 11001 describe removal of extensive eczematous or infected
skin.

CPT codes 11042-11047 should be used for debridement of relatively localized
areas depending upon the involvement of contiguous underlying structures.

CPT codes 97597 and 97598 **:**

  * If a simple dressing change is performed without any active wound procedure as described by these codes, do not bill these codes to describe the service.
  * CPT codes 97597 and 97598 are categorized by CMS as "sometimes therapy" services. If billed by a hospital subject to OPPS for an outpatient service, these CPT codes will be paid under the OPPS when the service is not performed by a qualified therapist and it is inappropriate to bill the service under a therapy plan of care.

Use of CPT codes 11000-11047 is not appropriate for the following services:
washing bacterial or fungal debris from feet, incision and drainage of abscess
including paronychia, avulsion of nail plates, acne surgery, destruction of
warts, or burn debridement. Report these procedures, when they represent
covered, reasonable and necessary services, using the CPT or HCPCS code that
most closely describes the service rendered.

CPT codes 11000 and 11001 are not appropriate for debridement of a localized
amount of tissue normally associated with a circumscribed lesion. Examples of
the inappropriate use of these codes are ulcers, furuncles, and localized skin
infections.

The following procedures are considered part of active wound care management,
and are not considered as debridement and are not included in the related LCD:
Removal of devitalized tissue from wound(s), non - selective debridement,
without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion),
including topical application(s), wound assessment, and instruction(s) for
ongoing care.

For services related to removal of callus (hyperkeratotic tissue) around an
ulcer, paring or cutting of corns, trimming or debridement of nails, please
refer to NGS LCD Routine Foot Care and Debridement of Nails (L33636).

Local infiltration, metacarpal/digital block or topical anesthesia are
included in the reimbursement for debridement services and are not separately
payable. Anesthesia administered by or incident to the provider performing the
debridement procedure is not separately payable.

The care of minor wounds (post-operative, traumatic, or otherwise) is
incidental to other covered services. Many claims for debridement are
essentially dressing changes and are not separately payable.

**Documentation Requirements:**

The patient's medical record must contain documentation that fully supports
the medical necessity for services included within the related LCD. (See
"Indications and Limitations of Coverage.") This documentation includes, but
is not limited to, relevant medical history, physical examination, and results
of pertinent diagnostic tests or procedures.

The medical record should include the following information:

  * An operative note or procedure note for the debridement service. This note should describe the anatomical location treated, the instruments used, anesthesia used if required, the type of tissue removed from the wound, the depth and area of the wound and the immediate post procedure care and follow-up instructions.
  * Identification of the wound location, size, depth and stage either by description and/or a drawing or photograph.
  * A description of the type(s) of tissue involvement, the severity of tissue destruction, undermining or tunneling, necrosis, infection or evidence of reduced circulation. If infection has developed, the patient's response to this infection should be described.
  * The patient's comorbid medical and mental condition, and all health factors that may influence the patient's ability to heal tissue, such as, but not limited to the following: mental status, mobility, infection, tissue oxygenation, chronic pressure, arterial insufficiency/small vessel ischemia, venous stasis, edema, type of dressing, chronic illness such as diabetes mellitus, uremia, COPD, malnutrition, CHF, anemia, iron deficiency, and immune deficiency disorders.
  * A determination of the initial treatment plan to include the expected frequency and duration of the skilled treatment and the potential to heal. Continuation of treatment plan with ongoing evidence of the effectiveness of that plan, including diminishing area and depth of the ulceration, resolution of surrounding erythema and /or wound exudates, decreasing symptomatology, and overall assessment of wound status (such as stable, improved, worsening, etc). Appropriate changes in the ongoing treatment plan to reflect the clinical presentation must be present in the record.

The documentation must include that if indicated, ongoing pressure relief has
been prescribed, for example, shoe inserts, modifications, padding, frequent
position changes, etc. and monitoring is occurring.

In cases of excessive frequency or prolonged duration of treatment,
documentation should include an evaluation for possible infection (e.g.
culture and sensitivity), osteomyelitis (e.g. x-ray), and treatment of any
infection by antibiotics. Any other conditions that may significantly affect
wound healing should also be appropriately addressed in the medical record.

Photographic documentation of wounds either immediately before or immediately
after debridement is recommended for prolonged or repetitive debridement
services (especially those that exceed five extensive debridements per wound
(CPT code 11043 and/or 11044)). If the provider is unable to use photographs
for documentation purposes, the medical record should contain sufficient
detail to determine the extent of the wound and the result of the treatment.

Supportive Documentation Requirements (required at least every 10 visits) for
97597 and 97598:

  * Etiology and duration of wound
  * Prior treatment by a physician, non-physician practitioner, nurse and/or therapist
  * Stage of wound
  * Description of wound: length, width, depth, grid drawing and/or photographs
  * Amount, frequency, color, odor, type of exudate
  * Evidence of infection, undermining, or tunneling
  * Nutritional status
  * Comorbidities (e.g., diabetes mellitus, peripheral vascular disease)
  * Pressure support surfaces in use
  * Patient's functional level
  * Skilled plan of treatment, including specific frequency, modalities and procedures
  * Type of debridement performed, including instrument used, to support the debridement code billed
  * Changing plan of treatment based on clinical judgment of the patient's response or lack of response to treatment
  * Frequent skilled observation and assessment of wound healing are recommended daily or weekly to justify the skilled service. At a minimum, the Progress Report must document the continuing skilled assessment of wound healing as it has progressed since the evaluation or last Progress Report.

Medical records must be made available to Medicare upon request.

**Utilization Guidelines:**

Cornerstones of chronic foot ulcer management include relief of pressure,
control of infection and appropriate debridement. While there is some
consensus that repeated debridement may promote more rapid healing of diabetic
foot ulcers, the appropriate interval and frequency of debridement depends on
the individual clinical characteristics of patients and ulcers. Reduction of
pressure and/or control of infection will facilitate healing and may reduce
the need for repeated debridement services. The treatment plan for a patient
who requires frequent repeated debridement should be reevaluated, to ensure
that pressure reduction and infection control have been adequately addressed.
In the presence of documented significant ischemic disease with necrotic
ulceration, extensive and definitive debridement may be required.

When the patient has required more debridement services per wound than defined
below, the medical record must include documentation reflecting neuropathic,
vascular, metabolic, or other comorbid conditions.

Debridement of diabetic foot ulcers more frequently than once every seven (7)
days, for a period longer than three (3) months may not be reasonable and
necessary. Services exceeding this intensity and duration of treatment will be
considered not medically necessary.

Debridement services are now defined by body surface area of the debrided
tissue and not by individual ulcers or wounds. For example, debridement of two
ulcers on the foot to the level of subcutaneous tissue, total area of 6 sq cm
should be billed as CPT code 11042 with unit of service of "1".

For patients with chronic wounds being treated in an outpatient setting,
services beyond the fifth surgical debridement, CPT code 11043, 11046 and/or
11044, 11047, per patient, per year, per wound may require a medical review of
records demonstrating the medical reasonableness and necessity. Providers are
reminded that the CPT code used to report the debridement must represent the
level of debridement and not the depth of the ulcer.

Initial debridement may be deep and through skin, subcutaneous tissue, muscle
fascia, and muscle. Subsequent debridement is often more superficial and best
described by CPT codes 97597 or 97598 rather than 11043 or 11044.