Article - Billing and Coding: Debridement Services (A56617)

CMS National Coverage PolicyN/AArticle TextThis 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 withinthe 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 woundPrior treatment by a physician, non-physician practitioner, nurse and/or therapistStage of woundDescription of wound: length, width, depth, grid drawing and/or photographsAmount, frequency, color, odor, type of exudateEvidence of infection, undermining, or tunnelingNutritional statusComorbidities (e.g., diabetes mellitus, peripheral vascular disease)Pressure support surfaces in usePatients functional levelSkilled plan of treatment, including specific frequency, modalities and proceduresType of debridement performed, including instrument used, to support the debridement code billedChanging plan of treatment based on clinical judgment of the patients response or lack of response to treatmentFrequent 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.