ED Coding and Reimbursement Alert

Question: We recently treated a patient who was involved in a skateboard accident, which resulted in him getting deep cuts on his left leg. Our ED provider noted that the wounds measured 30 sq. cm and that it had gravel in them that needed to be removed. Can we report 11042 with +11045 and 10120 together, and if we do, will we need to append a modifier?

Codify Subscriber

Answer: Your classification of the wound as "deep," and your provider's documentation of the total area of the wounds, suggests that you should be able to go ahead and document 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq. cm or less) with +11045(...  each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)) for the service rather than, say, 97597 (Debridement ... first 20 sq cm or less) and +97598 (... each additional 20 sq cm, or part thereof (List separately in addition to code for primaryprocedure)).

When you do, though, you should make sure that your provider's notes indicate that the procedure involved going deeper than the patient's epidermis or dermis and into the subcutaneous tissue. You should also make sure that the wounds were all debrided at the same depth, as CPT^® guidelines require you to "sum the surface area of those wounds that were at the same depth."

Reporting 11042 and +11045 with 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) is trickier. The two services are distinct and not bundled per CCI edits, but debridement often involves the removal of foreign bodies as well as dead or damaged tissue from a wound. So, when you report 11042, you are essentially saying that your physician also performed the service described by 10120.

However, if your physician's notes indicate that the debridement occurred in one anatomical area, say the knee, and the removal in another, say the shin, then you would have a case for documenting 11042 and +11045 with 10120. To be safe, you could append modifier 59 (Distinct procedural service) to either 11042 or 10120. This would not only alert your payer that the two services were separate but might also facilitate swifter processing of the claim.