ED Coding and Reimbursement Alert

Remember that all the codes in the CPT debridement sections are within the physician's scope of practice, so it pays to know the most common debridement scenarios. If you undercode your physician's debridement services, you could lose easy money.

Your ED physician will see many patients requiring surface-level debridement; he might also treat patients needing surgical bone and muscle debridement on occasion, confirms Sharon Richardson, RN, who works in the compliance office at Emergency Groups' Office in Arcadia, Calif.

So what makes a debridement claim stand out? "The debridement codes [often] focus on debridement 'to viable tissue,' according to CPT. CPT does not, however, require a margin of healthy tissue; sometimes that is impossible or can only be achieved with multiple staged procedures," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CCC, COBGC, CPC-I, manager of compliance education for the University of Washington Physicians Compliance Program.

Debridements are common in the ED; these procedures serve to immediately facilitate the repair of wounds associated with the disruption of soft tissue (for instance, skin, subcutaneous tissue, and muscle) and hard tissue (meaning bone) that often follow a traumatic injury, explains Kenneth Engel, CPC, CHC, ACS-EM, CCP-P, vice president and compliance officer for Martin Gottlieb and Associates in Jacksonville, Fla.

Common ED wounds such as "penetrating or blunt trauma often produce contaminated wounds, which require the debridement of tissue impregnated with foreign material, bacteria, or devitalized tissue," Engel explains.

Consider this example from Engel: A 76-year-old female presents to the ED with an acute dog bite to the forearm. The nurse practitioner (NP) examines and rules out foreign bodies, trims several devitalized and crushed flaps of partial-thickness skin, and applies antibiotic ointment and steri-strips. The NP then prescribes Augmentin and releases the patient.

In this instance, the NP provided debridement care (trimming viable tissue, ruling out foreign bodies). On the claim, report the following:

• 11040 (Debridement; skin, partial thickness) for the debridement

• the appropriate ED E/M code, such as 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...)

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M to show that the E/M was a separate service from the debridement

• 881.00 (Open wound of elbow, forearm, and wrist; without mention of complication; forearm) appended to 11040 and the E/M to represent the patient's injury.

Remember, your ED physician might provide debridement service more involved than 11040; be on the lookout for evidence that the procedure went deeper, and the payback will increase.

Consider this example from Bucknam: A motorcyclist is riding on a recently paved street when he hits loose gravel and tips over. The rider is wearing leather and a helmet, but he falls hard on his right knee, ripping through the leather and scraping skin off the knee and calf. Gravel and other road materials are embedded in the wound.

After examination, he is found to have only some bruises and scrapes, although the wounds on the knee and calf are the worst. The physician debrides the wound, including skin, some subcutaneous tissue, and all the foreign material in and surrounding it. The NP then places a topical antibiotic and dressings, and gives the patient a tetanus booster.

In this instance, the physician treated skin and subcutaneous tissue, meaning you should report the following:

• 11042 (... skin, and subcutaneous tissue) for the debridement

• the appropriate level E/M code with modifier 25 appended

• 891.1 (Open wound of knee, leg [except thigh], and ankle; complicated) appended to 11042 and the E/M to represent the patient's injuries

• E816.2 (Motor traffic vehicle accident due to loss of control, without collision on the highway; motorcyclist) appended to 11042 and the E/M to represent the cause of the patient's injuries.

Payout: The 11042 code pays about $45 (1.23 transitioned facility relative value units [RVUs] multiplied by the 2009 Medicare conversion rate of 36.0666.); code 11040 only pays about $26 (0.73 RVUs times 36.0666).