ED Coding and Reimbursement Alert

Reviewers took a close look at reporting debridement services.

Reporting wound debridement can be challenging in the emergency department, requiring you to differentiate the service from wound care management, and evaluate the depth of the wound that the physician debrided. A new Comparative Billing Report (CBR) has the details to help you figure out how you compare to other providers nationwide when it comes to billing this service.

Background: In 2018, CMS merged its CBR program with the Program for Evaluating Payment Pattern Electronic Reports (PEPPER) programs. Previously, Medicare Administrative Contractor (MAC) Palmetto GBA facilitated CBRs with its partner, consulting firm eGlobalTech. Now, RELI Group and its partners create CBRs and PEPPERs for CMS. Under this new management structure, the agency released CBR 202107 in July, homing in on claims issues with wound debridement codes.

Reminder: The feds use CBRs as a tool to offer insight into billing and coding trends across different specialties and health care settings. More importantly, the specialty comparisons allow Medicare providers to see how their claims match up against others in their states and across the nation in order to eradicate incorrect coding and circumvent outlier tendencies. Plus, the timely data lets you see where you stand when it comes to the frequency of billing certain services, codes, or modifiers, too.

Take a Look at the Findings

Before you consider what the findings were, it’s important to understand why reviewers examined this code set.

“Let’s take a look now at the vulnerability of correct payments for wound debridement, and how that plays into CMS’s protection of the Trust Fund,” said RELI’s Annie Barnaby during a July 21 presentation about the CBR. “The 2020 Medicare Fee-for- Service Supplemental Improper Payment Data report reflects a 9.1 percent improper payment rate for ambulatory procedures – skin, which represents $169 million in projected improper payments,” she said. “Within that error rate, there is a 95.7 percent improper payment rate due to insufficient documentation. These statistics give us a great look into why this is an area of interest for CMS in their protection of the Trust Fund.”

She noted that when the CBR refers to “wound debridement services,” it’s referring to the following codes:

• 11042 (Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less)
• +11045 (…each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure))
• 11043 (Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less)
• +11046 (…each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure))
• 11044 (Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less)
• +11047 (…each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure))

Check out the breakdown of how providers fared during the analysis.

Metric 1: Percentage of Claims Billed With Add-on Codes

To calculate the first metric, RELI divided the number of unique claims with add-on codes by the number of unique claims that included just a base code, a base code and an add-on code, or an add-on code only.

The national average is approximately 14 percent, Barnaby noted. However, providers in some areas far exceeded that, with the highest being in Guam, Washington, D.C., and Nevada, each of which exceeded 22 percent. The lowest rates were in the Virgin Islands, Vermont, and New Hampshire, all of which were below 7 percent.

To determine where you stand, calculate which percentage of your wound care claims are reported with the add-on codes (+11045, +11046, and +11047), and then compare that against your state’s average (which is in RELI’s “National and State Data” sheet at https://cbr.cbrpepper.org/About-CBR/CBR-202107) and the national average of 14 percent. 

Best practice: Although CPT^® doesn't offer an in-depth look at reporting the debridement codes, the AMA did cover them in the October 2016 issue of CPT^® Assistant, noting: “Debridement is the process of removing dead tissue from wounds. It can be accomplished by invasive methods such as scissors, scalpel, and/or forceps. Debridement codes 11042-+11047 are reported based on depth of tissue that is removed and total surface area of the wound(s). Depth is defined progressively from the skin level down through to the bone. For the debridement codes, surface area is defined as each section of 20 sq cm, or additional part thereof. To report debridement codes 11042-+11047, both criteria of depth and surface area should be met. The degree to which they are met determines the code reported.”

Metric 2: Percentage of Allowed Charge Amount From Add-on Codes

To calculate metric 2, RELI divided the total allowed charge amount for add-on codes by the total allowed charge amount for claims with a base alone, a base and an add-on code, or an add-on code only. The national average in this category is 13.3 percent, Barnaby noted.

The number varied greatly by state, with Washington, D.C. coming in the highest at 28.55 percent, followed by Mississippi and Georgia, both of which exceeded 20 percent. The lowest rate was observed in the Virgin Islands at 2.57 percent, followed by Puerto Rico, Montana, Vermont, and Utah, all of which logged rates below 7 percent.

Once you determine your average allowed amount from add-on codes, compare that against the national and state averages.

Best practice: If your average amounts billed are higher than the national or state average, it doesn’t necessarily mean you’re doing anything wrong, but it can be a reason to justify taking a deeper look at your charges and billing practices. This is why it’s so important to perform a fee schedule analysis at your practice.

Metric 3: Average Number of Units Per Claim Line With Add-on Codes

For the final metric, RELI divided the total number of units from claim lines with an add-on code by the number of total unique claim lines with an add-on code. Barnaby noted that the national average came in at just 2.83 units.

Minnesota was the state with the highest number of units per claim line with an add-on code at 4.16, followed by Kentucky and Maine. The three regions with fewer than 2.0 units per claim line were the Virgin Islands (1.74), Puerto Rico (1.83), and Nevada (1.86).

Best Practice: Your documentation should be impeccable if you want to back up your debridement claims. The AMA notes in the October 2016 edition of CPT^® Assistant that your procedure report should include all information that is pertinent to determining the depth and surface area debrided from a wound. “This code series is for the debridement of wounds when no direct primary closure, such as grafting, is anticipated,” the AMA adds.

Double-Check Your Billing and Coding Practices

“After looking at the projected improper payment rate and the cause of that being possible errors in insufficient documentation, we aim to have providers realize their role in the protection of the Trust Fund and offer analysis that can support internal reviews to confirm proper coding and documentation,” Barnaby said.

Resource: To read the comparative billing report, visit https://cbr.cbrpepper.org/About-CBR/CBR-202107.