ED Coding and Reimbursement Alert

In many cases, debridement performed in the emergency department will be included in whichever wound repair codes are assigned. However, there are instances when debridement may be reimbursed separately. To successfully report these codes, ED coders must understand when it is appropriate and what level of documentation is required.
 
Cindy McMahan, CPC, an independent coding consultant based in Albany, Wisc., notes that CPT is specific about when debridement is included in a closure code. It can be reported separately only when the wound is grossly contaminated and prolonged cleansing is required, she says. An example is a barnyard laceration with contamination. In order to justify the use of these codes in addition to wound repair codes (12001*-13160), the physicians notes must clearly state that the wound was significantly contaminated and should quantify the amount of saline or other substance used to cleanse the wound. McMahan adds that, when circumstances allow both types of codes to be assigned, modifier -59 (Distinct procedural service) should be appended to the debridement code. This informs the payer that the ED physician recognizes that debridement is generally bundled into wound repair, but that clinical circumstances require the separate service.
 
Notes in the CPT manual add that debridement codes may also be used independently of repair codes when large amounts of devitalized or contaminated tissue are removed, and when debridement is performed without immediate primary repair of a wound.

 
For example, a debridement code should be reported when an ED physician cleanses gravel, shards of glass or other particulate matter from road rash sustained in a motorcycle accident. When a patient comes in after a motorcycle accident, it is very likely that the physician will need to remove debris from the injury, very possibly without wound repair, says Betty Ann Price, RN, BSN, CCS-P, president of Professional Reimbursement and Coding Strategies, a consulting firm based in Palmetto, Fla. In this case, the debridement code would be used.
 
Choosing a code will depend upon the documentation in the medical record, she adds. This is where assigning these codes becomes difficult, she says. The physician must provide detail about the type of tissue and the layers that were involved for coders to determine the proper code.
 
When reporting this type of debridement, CPT offers five codes:

  11040 Debridement; skin, partial thickness (involves the epidermis and/or superficial epithelial layer of skin)

  11041 skin, full thickness (involves both the epidermis and dermis containing the blood vessels, nerves, nerve endings, glands and hair follicles)

  11042 skin, and subcutaneous tissue

  11043 skin, subcutaneous tissue, and muscle

  11044 skin, subcutaneous tissue, muscle, and bone.

 
Unfortunately, coders are often unable to report the service, because the ED physicians notes dont provide enough information, Price says. The doctor may dictate that a heavily contaminated wound was irrigated extensively to remove particulate matter but this doesnt give coders enough information to choose a code.  Many coding professionals recommend that ED physicians provide detailed descriptions or even illustrations of the tissues that were cleansed.

 
Although cleansing is most commonly performed immediately before a wound is repaired and the debridement code cant be reported separately, McMahan points out that the procedure may nonetheless factor into the repair code used. Debridement may allow the coder to assign a higher-paying repair code, she points out. CPT says that if a single layer closure wound requires extensive debridement, coders may instead assign an intermediate layer closure code.
 
When a simple repair is performed with minimal amounts of debridement, for instance, only a simple repair code would be assigned (12001*-12021). If that same wound needs extensive cleaning or removal of particulate matter, coders may instead report an intermediate repair code (12031*-12057). There is significant difference in payment between these two sets of code. The work relative value units (RVUs) for a 20.0-cm simple closure (12005) is 2.86, for example, but is 3.43 for a 20.0-cm intermediate repair (12035).
 
Medicare policy does not mimic CPT guidelines in this instance. To report an intermediate code, Medicare requires that the repair require a layered closure.

 
Price notes that CPT also offers two codes for removal of non-viable tissue: *11000 (Debridement of extensive eczematous or infected skin; up to 10% of body surface) and add-on code +11001 ( each additional 10% of the body surface [list separately in addition to code for primary procedure]). When calculating the percentage of body affected, coders would use the rule of nines found in the burn treatment section of CPT (16000-16036).
 
These codes are not often used by ED physicians, and are rarely associated with lacerations or similar injuries. Instead, they would be assigned when the physician removes skin that is severely eczematous, such as when it has been infected with a bacterial fungus or is necrotic. For instance, an elderly patient with diabetes and poor circulation may be treated in the ED for insulin shock. During the ED service, the physician may identify and remove non-viable tissue from the patients extremities. In this instance, the appropriate ED visit code may be assigned along with 11000 or 11001.

 
Codes 11010-11012 (e.g., 11010, Debridement including removal of foreign material associated with open fracture[s] and/or dislocation[s]; skin and subcutaneous tissues) describe debridement performed with open fractures and dislocations. As with debridement codes 11040-11044, codes from this set are selected based on the number of layers treated during debridement. These would be used, for instance, if a 44-year-old male fell from a ladder and suffered a fractured ulna, which protruded from the skin. Because the man fell into shrubbery and loose dirt, the surrounding skin was torn and contaminated with twigs, leaves and soil. The ED physician would report both the fracture care code and the debridement code (e.g., 11010).