Health Information Management

Cut through the confusion related to different kinds of wound debridements

JustCoding News: Outpatient, December 30, 2009

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It’s important to understand the distinctions among the different kinds of debridements that providers perform at outpatient wound care clinics to ensure accurate billing.

Excisional debridement

Excisional debridement is defined by the use of a sharp instrument (e.g., scalpel) to increase the wound size, said Gloria Miller, CPC, vice president of reimbursement services at Comprehensive Healthcare Solutions, Inc., in Tacoma, WA, during the November 30 HCPro audio conference, “Outpatient Wound Care Coding: Solve the Toughest Challenges.” The physician must remove viable tissue, and document whether bleeding occurred. Typically, there will be bleeding unless the patient has poor vasculature, in which case documentation should also reflect that the physician addressed the patient’s vascular status. Documentation should also detail how the physician addressed the patient’s pain control.

Use CPT® codes 11040–11044 to report excisional debridements, which physicians typically perform. Providers should assign the appropriate CPT code according to the type of tissue the physician removed and not the level of the debridement.

Consider an example in which a patient has a full thickness venous ulcer, and the physician removes only a partial thickness epidermal layer of tissue. This is viable tissue and may include skin. When the physician removes a partial thickness layer, providers should report CPT code 11040 (Debridement; skin, partial thickness), even though the ulcer’s depth is more significant.

Providers should bill for excisional debridements based on the number of ulcers. So when a patient has three separate and distinct ulcers, providers may bill for three separate debridements for that date of service if the physician documentation supports medical necessity.

Note that some local coverage determinations (LCD) limit the number of excisional debridements on an individual body part (e.g., multiple ulcers on a foot), Miller said. Some LCDs, for example, only allow providers to charge up to four excisional debridements for diabetic ulcers on a patient’s foot.

When there are separate and distinct ulcers elsewhere on the body, providers may charge separately for excisional debridements to those areas, she said.

“The important component you need to consider is the viable tissue component—that’s really the difference between an excisional and a selective debridement,” Miller said.

Selective debridement

A selective debridement refers to when a physician or other qualified professional, such as a registered nurse (RN) or physical therapist (PT) removes non-viable tissue. For example, a patient with a chronic ulcer may come to a wound clinic, and on the first visit the physician performs an excisional debridement because there is viable tissue intermingled with nonviable tissue in that ulcer. Then on subsequent visits, the debridements may be either excisional or selective.

Although providers bill excisional debridements per ulcer, they should bill selective debridements per visit. So when a patient has multiple ulcers, and the clinician performs selective debridement, providers may only charge one unit of selective debridement even if the clinician debrides 16 different ulcer sites, Miller said.

Selective debridement is also defined by the use of a sharp instrument when either a physician or RN provides this service. In addition to the criteria that there is removal of nonviable tissue, selective debridements mean that there is no increase in the wound size, typically no bleeding, and no pain control needed in these cases (because the tissue is not viable).

Report the following CPT codes for selective debridements:

  • 97597: Removal of devitalized tissue from wound(s); selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters
  • 97598: Removal of devitalized tissue from wound(s); selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area greater than 20 square centimeters

Nonselective debridement

A third type of debridement is a nonselective wound debridement. This is only a technical service, which means that the physician cannot charge for it, Miller said. Typically, an RN or PT performs nonselective wound debridements, which do not involve the use of sharp instruments.

Nonselective wound debridements generally involve nonsurgical brushing, irrigation, scrubbing, or washing of devitalized tissue, necrosis, or slough (e.g., whirlpool therapy, medicated dressings, pulse lavage).

Report CPT code 97602 (Removal of devitalized tissue from wound(s), nonselective debridement, without anesthesia [e.g., wet-to-moist dressings, enzymatic, abrasion], including topical application(s), wound assessment, and instruction(s) for ongoing care, per session) for facility payment only. Also, providers may report this code per visit not per ulcer, Miller said.

Documentation for debridement

As with all coding, documentation is critical. Documentation of debridements should include the following:

  • Excisional or nonexcisional; selective or nonselective
  • Medical decision-making to support medical necessity
  • Location and characteristics of wound(s)
  • Type of tissue removed
  • Depth of procedure
  • Amount of bleeding and measures taken to control bleeding
  • Instrument used and its size
  • Patient’s pain tolerance and pain control methods
  • Dressing applied and follow-up treatment plan

For examples of how to document the different types of debridements, access a dictation template for excisional debridements that Miller provided.

This is a broad look at typical documentation requirements related to debridement procedures, but check with your fiscal intermediary (FI). Some FIs may want providers to document more information, such as bleeding or pain control.

Miller suggested providers conduct quarterly or six-month audits of their documentation. “Take a step back with a critical eye and look at your documentation. See if you’re really capturing all the information that you need, and modify it as you need to,” she said.

Editor’s note: E-mail Miller at MILLERX7@aol.com.

To learn more about coding for skin substitutes and the use of modifiers, purchase a copy of HCPro’s audio conference “Outpatient Wound Care Coding: Solve the Toughest Challenges,” which was held on November 30, 2009.



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