Medicare Compliance & Reimbursement

Patients who present to your practice for debridement pose a challenge for coders because there are misconceptions floating around about how to properly assign active wound care management (AWCM) codes 97597-97598.

Add to that the confusion regarding selective versus surgical debridement, and you have a potential coding challenge on your hands.

Question: Who can provide the 97597-97598 service?

Answer: Nonphysician practitioners (NPPs) licensed to perform these procedures (for example, physician assistants, nurse practitioners, physical therapists) typically report 97597-97598. CPT designed 97597 (Removal of devitalized tissue from wound[s], selective debridement ... total wound[s] surface area less than or equal to 20 square centimeters) and 97598 (... total wound[s] surface area greater than 20 square centimeters) for reporting by licensed nonphysician professionals.

Because licensure and state laws vary from state to state, you'll have to check your individual policies to see what "qualifies" an NPP to perform these debridements.

Note: Most physicians do not directly perform these debridement services. But if they do, check your contracts to make sure the payer accepts 97597-97598 when the physician performs the service.

Remember to use 97597-97598 only for encounters during which the provider meets the codes' parameters, says Sharon Richardson, RN, compliance officer with Emergency Groups' Office in Arcadia, CA.

Question: What are the parameters for 97597-97598?

Answer: When the wound management provider performs selective debridement on a patient, you would code the service with 97597, says Jeffrey Linzer, MD, MICP, FAAP, FACEP, associate medical director of compliance and business affairs for the division of pediatric emergency medicine Department of Pediatrics at Children's Healthcare of Atlanta at Egleston.

Selective debridement means removing devitalized tissue from the wound, Richardson says. During selective debridement, the provider does not treat any healthy tissue, only the devitalized tissue.

Check out this definition from Diversified Clinical Services, a consulting firm in Jacksonville, FL. Note how the definition specifies "devitalized tissue":

"Selective debridement is the removal of devitalized tissue (including fibrin, exudates, crusts, and other non-tissue materials) from wounds, without general anesthesia (e.g., high-pressure water jet with/without suction, sharp selective debridement with scissors, scalpel, or forceps), with or without topical applications."

"It's basically removal of dead tissue that is sitting on top of the wound and keeping it from healing," Richardson says of selective debridement. Remember that your provider might use aggressive means of tissue removal for this service, including scissors, curettes, water pressure, etc.

No matter the tools of removal, the service is still a selective debridement as long as the provider is not treating healthy tissue, Richardson says.

Consider this example from Linzer:

A patient who recently underwent treatment for a 2-cm x 2-cm infected carbuncle on the back of his hand reports to the wound care clinic for a checkup on the injury. The provider examines the wound and removes some devitalized tissue and fibrin from the wound margin with a high-pressure waterjet, and then dresses the wound.

This is an example of a 97597 service. On the claim, report the following:

• 97597 for the wound care

• 680.4 (Carbuncle and furuncle; hand), V58.49 (Other specified aftercare following surgery) and V58.31 (Encounter for change or removal of surgical wound dressing) linked to 97597 to prove medical necessity for the service.

ICD-9 explanation: In this example, the first ICD-9 code represents the patient's carbuncle. "The V codes show care for the residual state of the infection," Linzer says.

Question: Who can provide the 11000-11044 service?

Answer: Either a physician or a qualified NPP can report services using debridement codes 11000 (Debridement of extensive eczematous or infected skin; up to 10 percent of body surface) through 11044 (Debridement; skin, subcutaneous tissue, muscle and bone). If the performing NPP is qualified and the visit meets the parameters for 11000-11044, you can report these codes, Richardson says.

Question: What are the parameters for 11000-11044?

Answer: When the physician or NPP performs surgical debridement, you should report the service with a code from the 11000-11044 series, Linzer says. Surgical debridement means cutting outside the margins of the wound's width or depth into healthy tissue just outside the wound. "So if the debridement is getting down to healthy tissue, then you'd use the 11000-11044 codes," Richardson says.

Example: A 46-year-old patient with type II uncontrolled diabetes presents to the emergency department (ED) with diabetic ketoacidosis. During a level-four service, the ED physician discovers cellulitus of the left leg with small areas of necrotic tissue surrounding several wounds. The physician performs significant debridement of the infected tissue while starting high-dose antibiotics.

In this scenario, the physician performed surgical debridement. On the claim, report the following:

• 11000 (Debridement of extensive eczematous or infected skin; up to 10 percent of body surface) for the debridement service

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity) for the E/M

• 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 99284 to show that the E/M and debridement were separate services

• 682.6 (Other cellulitus and abscess; leg, except foot) linked to 99284 and 11000 for the patient's wound

• 250.12 (Diabetes with ketoacidosis; type II or unspecified type, uncontrolled) linked to 11000 and 99284 to represent the patient's diabetes.