Otolaryngology Coding Alert

Question: I need help coding for a tracheostomy debridement. I’ve been using 11042 with diagnosis 519.01 because I cannot find a code specific for the tracheostomy, but Medicare is now giving me “not medically necessary” denials. Are there better CPT® or ICD-9 codes I could be using to avoid these denials? 

Montana Subscriber

Answer: CPT® does not currently include a specific code for debridement of the trachea or tracheal area. Debridement codes are not site specific, but are based on the square centimeters of the area debrided. You should only report 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) if your provider clearly documents removal of subcutaneous tissue. Anything less than that (such as partial or full thickness) would be coded with 97597 (Debridement [e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application[s], wound assessment, use of a whirlpool, when performed and instruction[s] for ongoing care, per session, total wound[s] surface area; first 20 sq cm or less) or 97598 (… each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure]), based on the square centimeters removed. 

Your diagnosis code should support the medical necessity for the debridement. You may need to query Medicare to see what exactly they mean by “not meeting medical necessity” and to verify that 519.01 (Infection of tracheostomy) is an approved diagnosis for the procedure. Check if your Medicare carrier has a LCD (local coverage determination) that limits the diagnoses for the debridement code you are using to support medical necessity. There is a chance that 519.01 is not on that list. Note that if you submit 519.01, CPT® directs you to also report a code identifying the type of infection and/or infectious organism. 

If everything seems to be in order, appeal the decision. You might have to go to the second level of appeal, Reconsideration, to get a positive result. Keep in mind that even though you win your appeal, it does not change the LCD (if there is one). You will need to go to your Carrier’s medical director and the Carrier Advisory Committee and request that they add 519.01 to the list of “medically necessary” diagnoses within the LCD. You will accomplish this by showing why the debridement is needed for this condition.