Procedure codes 11042, 11043, 11044 , 97597 - Debridement tissue

procedure code and description

11042-Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 square cm or less.  - average fee payment- $120 - $130

11045 (add-on code for 11042) each additional 20 square cm, or part thereof.

 11043 Debridement, muscle and/or fascia (includes epidermis, dermis and subcutaneous tissue, if performed); first 20 square cm or less.

11046 (add-on code for 11043) each additional 20 square cm, or part thereof.

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 square cm or less. procedure  +11047 (add-on code for 11044) each additional 20 square cm, or part thereof.



Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

    Debridement is the removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound. Debridement promotes wound healing by reducing sources of infection and other mechanical impediments to healing.

    Debridement services will be considered medically reasonable and necessary when they are provided for the management of wounds and ulcers of the skin and underlying tissue to promote optimal wound healing or to prepare sites for appropriate surgical intervention. The requirements for reasonable and necessary service(s) include safe and effective debridement methods most appropriate to the type of wound, furnished in the appropriate setting, and ordered and/or performed by qualified personnel.

    Skin Debridement (procedure  codes 11000-11001)

    procedure  codes 11000 and 11001 describe removal of extensive eczematous or infected skin. Conditions that may require debridement of large amounts of skin include: rapidly spreading necrotizing process (sometimes seen with aggressive streptococcal infections), severe eczema, bullous skin diseases, extensive skin trauma (including large abraded areas with ground-in dirt), or autoimmune skin diseases (such as pemphigus).

    procedure  code 11001 is not appropriate for debridement of a localized amount of tissue normally associated with a circumscribed lesion. Examples of this are ulcers, furnucles, and localized skin infections.

    Debridement of Necrotizing Soft Tissue Infections (procedure  codes 11004-11008)

    procedure  codes 11004-11006 describe extensive debridement of skin, subcutaneous tissue, muscle, and fascia to treat necrotizing soft tissue infections. Generally, these debridement procedures are performed on high-risk patients. The code descriptor indicates the specific area that receives treatment.

    procedure  code 11008 describes the concurrent removal of a mesh or prosthetic device.

    Surgical Debridement (procedure  codes 11042-11047)

    Surgical debridement occurs only if material has been excised and is typically reported for the treatment of a wound to clear and maintain the site free of devitalized tissue including necrosis, eschar, slough, infected tissue, abnormal granulation tissue etc., to the margins of viable tissue. Surgical excision includes going slightly beyond the point of visible necrotic tissue until viable bleeding tissue is encountered in some cases. The use of a sharp instrument does not necessarily substantiate the performance of surgical excisional debridement. Unless the medical record shows that a surgical excisional debridement has been performed, debridements should be coded with either selective or non-selective codes (97597, 97598, or 97602).

    Surgical debridement codes (11042-11047), as performed by physicians and qualified non-physician practitioners licensed by the state to perform those services,are reported by depth of tissue removed and by surface area of the wound. These codes can be very effective but represent extensive debridement, often painful to the patient, and could require complex, surgical procedures and sometimes require the use of general anesthesia. Surgical debridement will be considered as “not medically necessary” when documentation indicates the wound is without infection, necrosis, or nonviable tissues and has pink to red granulated tissue.

    Documentation for surgical debridement procedures should include the indications for the procedure, the type of anesthesia if and when used, and the narrative of the procedure that describes the wounds, as well as the details of the debridement procedure itself. The procedure  code selected should reflect the level of debrided tissue (e.g.,skin, subcutaneous tissue, muscle and/or bone), not the extent, depth, or grade of the ulcer or wound. For example, procedure  code 11042 defined as “Debridement, subcutaneous tissue” should be used if only necrotic subcutaneous tissue is debrided, even though the ulcer or wound might extend to the bone. In addition, if only fibrin is removed, this code would not be billed.

    It would not be expected that an individual wound would be repeatedly debrided of skin and subcutaneous tissue because these tissues do not regrow very quickly.

    Active Wound Care Management

    Debridement is indicated whenever necrotic tissue is present on an open wound. Debridement may also be indicated in cases of abnormal wound healing or repair. Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue. This procedure includes wound assessment; debridement; application of ointments, creams, sealants, and other wound coverings; and instructions for ongoing care. It should be billed no more than once per day, regardless of the number of wounds.

    Selective Debridement (97597 and 97598)

    procedure  codes 97597 and 97598 are used for the removal of specific, targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue. Occasional bleeding and pain may occur. The routine application of a topical or local anesthetic does not elevate active wound care management to surgical debridement. Selective debridement includes:

        Selective removal of necrotic tissue by sharp dissection including scissors, scalpel, and forceps

        Selective removal of necrotic tissue by high pressure water jet

    Coverage for wound care on a continuing basis for a given wound in a given patient is contingent upon evidence documented in the patient’s medical record that the wound is improving in response to the wound care being provided. It is neither reasonable nor medically necessary to continue a given type of would care if evidence of wound improvement cannot be shown.

    Evidence of improvement includes, but is not limited to, measurable changes in at least some of the following:

        Drainage (color, amount, consistency)

        Inflammation

        Swelling

        Pain

        Wound dimensions (diameter, depth, tunneling)

        Granulation tissue

        Necrotic tissue/slough

    Such evidence must be documented with each visit. A wound that shows no improvement after 30 days requires a new approach, which may include a reassessment, by a qualified professional, of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new plan of care or treatment method.

    In rare instances, the goal of wound care provided in the outpatient setting may only be to prevent progression of the wound, which, due to severe underlying debility or other factors such as inoperability, is not expected to improve.

    LIMITATIONS

    The following services are not considered to be wound debridement:

        Removal of necrotic tissue by cleansing, scraping (other than by a scalpel or a curette), chemical application, and wet-to-dry dressing.
        Washing bacterial or fungal debris from lesions.
        Removal of secretions and coagulation serum from normal skin surrounding an ulcer.
        Dressing of small or superficial lesions.
        Removal of fibrinous material from the margin of an ulcer.
        Paring or cutting of corns or non-plantar calluses. Skin breakdown under a dorsal corn that begins to heal when the corn is removed and shoe pressure eliminated is not considered an ulcer and does not require debridement unless there is extension into the subcutaneous tissue.
        Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, or destruction of warts. Providers should report these procedures, when they represent covered, reasonable and necessary services, using appropriate procedure  or HCPCS codes.




Bill Type Codes

    Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

    12 Hospital Inpatient (Medicare Part B only)
    13 Hospital Outpatient
    22 Skilled Nursing - Inpatient (Medicare Part B only)
    23 Skilled Nursing - Outpatient
    71 Clinic - Rural Health
    74 Clinic - Outpatient Rehabilitation Facility (ORF)
    75 Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
    85 Critical Access Hospital


procedure /HCPCS Codes
 
    11001 Debride infected skin add-on
    11000 Debride infected skin
    11042 Deb subq tissue 20 sq cm/<
    11043 Deb musc/fascia 20 sq cm/<
    11044 Deb bone 20 sq cm/<
    11045 Deb subq tissue add-on
    11046 Deb musc/fascia add-on
    11047 Deb bone add-on
    97597 Rmvl devital tis 20 cm/<
    97598 Rmvl devital tis addl 20cm/<


Billing Guidelines

*A. Wound Care (CPT Codes 97597, 97598 and 11042-11047)

1. Active wound care is performed to remove devitalized and/or necrotic tissue to promote healing of a wound on the skin. These services are billed when an extensive cleaning of a wound is needed prior to the application of dressings or skin substitutes placed over or onto a wound that is attached with dressings.

2. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed.

3. CPT 97597 and/or CPT 97598 are typically used for recurrent wound debridements.

4. CPT 97597 and/or CPT 97598 are not limited to any specialty.

Coding Guidelines

1. Active wound care, performed with minimal anesthesia is billed with either CPT code 97597 or 97598.

2. Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 - 11047.


3. CPT code 11044 or CPT code 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory care center (ASC).

ICD-10 Codes that Support Medical Necessity


    The diagnoses listed below are applicable to the procedure /HCPCS codes listed above in both Group 1 (Part A) and Group 2 (Part B).
 

    A48.0 Gas gangrene
    B35.0 Tinea barbae and tinea capitis
    B35.1 Tinea unguium
    B35.2 Tinea manuum
    B35.3 Tinea pedis
    B35.4 Tinea corporis
    B35.5 Tinea imbricata
    B35.6 Tinea cruris
    B35.8 Other dermatophytoses
    B35.9 Dermatophytosis, unspecified
    I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
    I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf
    I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle
    I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot
    I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot
    I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg
    I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site
    I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
    I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf
    I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle
    I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot
    I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot
    I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg
    I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site
    I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg
    I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg
    I70.263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
    I70.268 Atherosclerosis of native arteries of extremities with gangrene, other extremity
    I70.269 Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity
    I70.331 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of thigh
    I70.332 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of calf
    I70.333 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of ankle
    I70.334 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.335 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of foot
    I70.338 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.339 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of unspecified site
    I70.341 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of thigh
    I70.342 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of calf
    I70.343 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of ankle
    I70.344 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of heel and midfoot
    I70.345 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of foot
    I70.348 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of lower leg
    I70.349 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of unspecified site
    I70.35 Atherosclerosis of unspecified type of bypass graft(s) of other extremity with ulceration
    I70.431 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of thigh
    I70.432 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of calf
    I70.433 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of ankle
    I70.434 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.435 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of foot
    I70.438 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.439 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of unspecified site
    I70.441 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh
    I70.442 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of calf
    I70.443 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of ankle
    I70.444 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of heel and midfoot
    I70.445 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of foot
    I70.448 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of lower leg
    I70.449 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of unspecified site
    I70.45 Atherosclerosis of autologous vein bypass graft(s) of other extremity with ulceration
    I70.531 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh
    I70.532 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of calf
    I70.533 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of ankle
    I70.534 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.535 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of foot
    I70.538 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.539 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of unspecified site
    I70.541 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh
    I70.542 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of calf
    I70.543 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of ankle
    I70.544 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of heel and midfoot
    I70.545 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of foot
    I70.548 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of lower leg
    I70.549 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of unspecified site
    I70.55 Atherosclerosis of nonautologous biological bypass graft(s) of other extremity with ulceration
    I70.631 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh
    I70.632 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of calf
    I70.633 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of ankle
    I70.634 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.635 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of foot
    I70.638 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.639 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of unspecified site
    I70.641 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh
    I70.642 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of calf

Documentation Requirements

1. The medical record must clearly show that the criteria listed in LCD GSURG-051 under “Indications and Limitation of Coverage and/or Medical Necessity” have been met.

2. There must be a documented plan of care with documented goals and documented provider follow-up present in the patient's medical record. Wound healing must be a medically reasonable expectation based on the clinical circumstances documented.

3. Documentation of the progress of the wound’s response to treatment must be made for each service billed. At a minimum this must include current wound size, wound depth, presence and extent of or absence of obvious signs of infection, presence and extent of or absence of necrotic, devitalized or non-viable tissue, or other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown.

4. When debridements are performed, the debridement procedure notes must document tissue removal (i.e. skin, full or partial thickness; subcutaneous tissue; muscle; and/or bone), the method used to debride (i.e., hydrostatic versus sharp versus abrasion methods), and the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement.

5. When, the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.


No comments:

Top Medicare billing tips