ED Coding and Reimbursement Alert

When reporting debridementspartial thickness, full thickness, skin and subcutaneous tissuehow do you know which codes to use? asks Kay Spading, RHIT, coding specialist at Marengo Memorial Hospital in Marengo, Iowa.

The answer lies mainly in getting ED physicians to provide adequate documentation of the debridement and decontamination procedures performed, says Betty Ann Price, RN, BSN, CCS-P, president of Professional Reimbursement and Coding Strategies, a consulting firm based in Palmetto, Fla.

The physician documentation should clearly indicate the extent of the injury by illustration and/or detailed description, she states. It is virtually impossible to presume the depth and layers of debrided tissue, for example, without specific indication by the physician.

When emergency department (ED) physicians repair deep lacerations, complex fractures and other open wounds, they often must cut away skin and subcutaneous tissue that has been so badly damaged it cannot be repaired. This process, called debridement, allows the still healthy skin and/or tissue to be closed, letting the wound heal. Physicians and ED staff may also spend a lot of time cleaning a dirty wound or removing contaminating materials (i.e., glass shards, splinters, other foreign objects) from the wound prior to closure.

Physicians can report these services, in addition to the wound repair, with the CPT Excision-Debridement codes (11000*-11044) in the Surgery/Integumentary System section of CPT.

Note: The wound repair is reported with codes in the range 12001-13160 in the Repair (Closure) heading in the same section. The excision-debridement codes are not used to report dermabrasions, nail debridements or treatment of burns. Those procedures have separate codes.

Debridement Included in Wound Repair Code

A limited amount of debridement and cleansing is included in the code for the wound repair, adds Price.

According to CPT 2000, debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately from primary closure. So, how should the coder know when the debridement is separately reportable?

Again, the documentation should be clear, says Price. Some examples of debridement would include the documentation indicating, large amounts of devitalized tissue dissected from the area of injury and grossly contaminated wound jet irrigated extensively with 500 cc of saline with excellent results.

Coders tip: It is also important to note that, when assigning the code for wound repair, single-layer wounds that require extensive debridement will usually warrant an intermediate repair code and, in some cases, a complex repair code, Price adds.

Codes 11000* and 11001

For debridement of extensive eczematous or infected skin, codes 11000* (debridement of extensive eczematous or infected skin; up to 10% of body surface) and 11001 (each additional 10% of the body surface [list separately in addition to code for primary procedure]) should be used.

The codes are used when the physician removes skin that is either excessively eczematous, infected with a bacterial fungus or necrotic, advises Caral Edelberg, CPC, CCS-P, president of Medical Management Resources Inc., an emergency medicine coding company based in Jacksonville, Fla. These injuries are not necessarily associated with a laceration or other injury, but may be the result of a severe infection or loss of circulation to the area affected.

The skin is either removed through abrasion (rubbing away with friction) or with a scalpel. The first code is used for up to 10 percent of the body surface, she adds.

When calculating the percentage of body area covered, coders should refer to the rule of nines chart listed with the burn treatment codes 16000-16035 in the Surgery/Integumentary section.

Codes 11010-11012

For patients with severe fractures or dislocations that have been contaminated with foreign material and/or when much of the skin and underlying tissue is severely damaged, CPT indicates separate debridement/excision codes.

Codes 11010-11012 are used for debridement including removal of foreign material associated with open fractures and or dislocations, according to CPT.

For example, a man suffers an open fracture of the left humerus (upper arm) in an automobile accident. One portion of the broken bone protrudes from the skin, and the surrounding skin has been severely torn and contaminated with broken glass and dirt.

ED clinicians must clean the wound of broken glass and dirt and remove dead tissue before the fracture can be stabilized or set. A separate code for debridement should be used, depending on the level of decontamination the wound requires.

Code 11010 is for debridement of the skin and subcutaneous tissues. Code 11011 should be used when the debridement involves the skin, subcutaneous tissue, muscle fascia, and muscle. Code 11012 is used when the foreign material and damage is deeper and involves the skin, subcutaneous tissue, muscle fascia, muscle and bone.

There is no way for the coders reporting debridement associated with fractures and dislocations to know whether the appropriate code is 11010 or 11012 unless the documentation specifically states the extent of debridement performed, says Price.

Physician documentation should indicate the level of contamination and/or the level of debridement required to remove the dead or devitalized tissue. For example, documentation that could indicate 11012 would be wound contamination to the bone, says Price.

Skin and subcutaneous tissue means the upper layers of skin and the tissue below, containing the deep capillary network, fat deposits, corpuscles, and hair bulbs, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., a coding consulting firm based in Dallas, Ga.

Codes 11040-11044

Codes 11040-11044 are for debridement of skin that is not associated with a bone fracture or dislocation. The codes assigned will reflect the level of tissue debrided, i.e., partial thickness, full thickness, or subcutaneous tissue. For example, code 11040 is for debridement, skin, partial thickness. This is for debridement that involves just the epidermis, or superficial epithelial layer of skin, Parman says.

Code 11041 is for skin, full thickness and should be used when the physician performs debridement of both the epidermis and dermis, which contains the blood vessels, nerves and nerve endings, glands and most of the hair follicles.

Code 11042 is for skin and subcutaneous tissue. Code 11043 is for skin, subcutaneous tissue and muscle, and code 11044 is for debridement that involves all of the layers down to the bone. These would require physician dictation of the words muscle or bone indicating the level of debridement, she says.

Documentation Affects Reimbursement

If physician documentation does not provide enough information to assign an appropriate debridement code, the coder must choose a lower-level code or, in some cases, no code at all. This can significantly affect reimbursement.
For example, if the coder knows the physician performed extensive debridement and cleansing of an open dislocation, but the documentation does not reflect what level of debridement was necessary, the coder will simply assign code 11010. But, if the physician actually removed contaminants from the fascia, muscle and bone, code 11012 should be used.

According to the 2000 Medicare Physician Fee Schedule, code 11010 is worth 4.20 physician work relative value units (RVUs), but code 11012 is worth 6.88 physician work RVUs.

Coders should point out this difference in reimbursement to their physicians if they believe they are missing the boat with excision and debridement coding.