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Deborah Grider, CPC, CPC-P, CPC-I, COC, CPMA, CEMC, CCS-P, CDIP
The wound care (97597-97598) and debridement codes (11042-11047) are used for debridement of wounds that are intended to heal by secondary intention. Some conditions that support medical necessity include infections, chronic venous ulcers, and diabetic ulcers, to name a few.
Many insurance carriers, including Medicare, have medical policies regarding wound care. It is important that there be a documented plan of care with documented treatment goals. Medical necessity must be supported in the documentation for performing wound care services.
Wound care patients often have underlying medical conditions that require concomitant management and may also require education, other services, and coordination of care. An evaluation and management (E/M) service on the same day as a debridement service should not be billed unless it is a “separately identifiable service” distinct from the debridement service. If the provider is managing wound care in addition to other conditions, the provider may report an E/M service with Modifier 25 appended to the E/M service. If the sole purpose of the visit is wound care management, only the wound care codes should be reported. A separate procedure note should be documented in the medical record.
Active Wound Care Management Codes
Active wound care procedures are performed to remove devitalized and/or necrotic tissue and promote healing. The provider is required to have direct (one-on-one) patient contact. These procedure have a 0 global period. These codes include the use of topical applications, suction, whirlpool wound assessment, and instructions for ongoing care. CPT codes 97597 and 97598 are used for wet-to-dry dressings, application of medications with enzymes to dissolve dead tissue, whirlpool baths, minor removal of loose fragments with scissors, scraping away tissue with sharp instruments, debridement with pulse lavage, high-pressure irrigation, incision, and drainage. These codes involve the dermis and epidermis only.
Coding Tip: For wounds that are being surgically excised in preparation for closure, refer to the 1500x codes below.
Wound debridement codes (not associated with fractures) are reported with CPT codes 11042-11047. Wound debridements are reported by the depth of tissue that is removed and the surface area of the wound. These services may be reported for injuries, infections, wounds, and chronic ulcers. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of the wounds that are at the same depth, but do not combine sums from different depths. These procedures require the use of forceps, scissors, scalpel, or tissue nippers. The codes are used when the wound is intended to heal by secondary intention.
For example: When bone is debrided from a 4-cm2 heel ulcer and from a 10-cm2 ischial ulcer, report the work with a single code, 11044. When subcutaneous tissue is debrided from a 16-cm2 dehisced abdominal wound and a 10-cm2 thigh wound, report the work with 11042 for the first 20 cm2 and 11045 for the second 6 cm2 . If all four wounds were debrided on the same day, use modifier 59 with either 11042 or 11044, as appropriate.
The diagnosis is usually an open wound such as a chronic venous stasis ulcer, pressure sore, or traumatic open wound that will not be closed in the near future. Make sure the ICD-10-CM code assigned is specific and that documentation supports the diagnosis code selected.
Coding Tips: Do not report codes 11042-11047 in conjunction with codes 97597-97602 for the same wound. For wounds that are being surgically excised in preparation for closure, refer to the 1500x codes below.
Surgical Preparation and Wound Excision Codes
These codes are used for wound preparation in anticipation of immediate or near-future surgical reconstruction (e.g., flaps, grafts, burns, traumatic wounds, or necrotizing infection). These codes are also used for debridement of wounds that will be or are surgically closed. Codes are chosen based on anatomic area as well as surface area of the wound or total body surface area for infants or children.
Anatomic area covered: