General Surgery Coding Alert

Don't forget about ostectomy: In some cases the above codes also describe removal of underlying bony structure (ostectomy) which may also become infected says M. Trayser Dunaway MD FACS a general surgeon in private practice in Camden S.C. For example 15931 describes excision of a sacral pressure ulcer while 15933 describes the same procedure but with further removal of bone below the site of the ulcer.

Closure type matters: You must choose between at least two codes to describe the type of closure the surgeon used for each ulcer location. The first code (for instance 15920 Excision coccygeal pressure ulcer with coccygectomy; with primary suture) describes closure by sutures while the second code (for example 15922 ... with flap closure) describes a closure using skin flaps.

Question 3: How Deep Was the Debridement?
 
When assigning debridement codes you must know the depth of the tissue the surgeon removed. This information is crucial because without supporting documentation you can only report the most superficial debridement code (11040 Debridement; skin partial thickness). But if the surgeon actually debrided all the way to muscle and bone (11044) and you only report 11040 you could lose up to $150 in payment simply because the documentation wasn't sufficient.

Make sure the medical record is complete: When debriding an ulcer the surgeon should note not only the location of the ulcer but also the depth/layers of the debridement (partial thickness 11040; full thickness 11041 subcutaneous 11042; subcutaneous and muscle 11043; or subcutaneous tissue muscle and bone 11044).

Tip: Report Muscle/Skin Grafts Separately

When the surgeon closes a sacral ischial or trochanteric ulcer excision using muscle flaps or skin grafts you should report a separate code to describe the closure according to CPT guidelines.

For example the surgeon excises an ischial pressure ulcer with ostectomy. She then closes the operative wound using muscle flap. To report the excision you should use 15946 (Excision ischial pressure ulcer with ostectomy in preparation for muscle or myocutaneous flap or skin graft closure). Per CPT instructions you may report the muscle flap closure separately using 15734 (Muscle myocutaneous or fasciocutaneous flap; trunk).

Apply -58 for Debridements Following 11044

If the surgeon performs 11043 or 11044 and reports subsequent debridements within the global period of the initial surgery you must append modifier -58 (Staged or related service by the same physician during the postoperative period) to the subsequent debridement codes.

Example: The surgeon debrides a pressure sore above the coccyx also removing muscle and bone to clear infection. You report 11044. Several weeks later -- within the global period of 11044 -- the surgeon must perform a subcutaneous debridement to remove additional diseased tissue. You should report this procedure using 11042-58.

Note: The global period for 11043 is 10 days as opposed to 90 days for 11044.

Don't worry about -58 for 11040-11042: Because codes 11040-11042 include zero global days you need not append modifier -58 to any subsequent debridements following these procedures.

For example the surgeon performs a full-thickness debridement followed 10 days later by a partial-thickness debridement. Report the first procedure 11041. Report the second procedure 11040 with no modifiers attached.

Avoid Active Wound Care Codes for Surgeons

Never use active wound care codes 97601 (Removal of devitalized tissue from wound[s]; selective debridement without anesthesia [e.g. high-pressure waterjet sharp selective debridement with scissors scalpel and tweezers] including topical application[s] wound assessment and instruction[s] for ongoing care per session) and 97602 (... ; non-selective debridement ...) to report surgeon management of decubitus ulcers. CPT includes these codes to describe debridements as performed by licensed nonphysician practitioners such as physician assistants nurse practitioners and clinical nurse specialists.

Surgeons should instead rely on debridement codes 11040-11044 to report wound care according to the AMA's CPT Changes 2001: An Insider's View. And you should never report 97601/97602 and 11040-11044 at the same time.