ED Coding and Reimbursement Alert

Question: A 36-year-old male patient presented to the ED following a cycling accident, which resulted in deep cuts on his leg. The ED physician documented wounds measuring 30 sq. cm with small rocks in them requiring removal as well as some debridement down to and including the subcutaneous tissue involving both the epidermis and dermis. Which codes should we report?

Tennessee Subscriber

Answer: Your procedure note appears to include both debridement of epidermis and dermis as well as your provider’s documentation of the total area of the wounds, suggesting that you should be able to report 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.

When you do, though, you should make sure that your provider’s notes indicate that the procedure involved epidermis, dermis, and components of the subcutaneous tissue. Although CPT^® instructs you to report the depth using the deepest level of tissue removed for a single wound, for multiple wounds 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 versus 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) is trickier. The two services are distinct and are bundled per National Correct Coding Initiative (NCCI) edits, but debridement often involves the removal of foreign bodies as well as dead or damaged tissue from a wound.

However, if your physician’s notes indicate that the debridement occurred in one anatomical area, say the knee, and a formal incision and removal in another area, say the shin, then you would have a case for documenting 11042 and +11045 with 10120. You would apply modifier 59 (Distinct procedural service) or the appropriate X modifier 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.