Part B Insider (Multispecialty) Coding Alert

One is an NPP code, the other requires more certification

Getting to the bottom of debridement coding doesn't necessarily mean choosing the deepest layer of tissue.
 
Many providers may have been unintentionally upcoding debridement claims (CPT Codes 11040-11044) according to a posting on Part B carrier Cigna Healthcare's Web site. "Medical reviews have found that providers are confusing the depth of the wound versus the type of tissue removed when billing for debridement."
 
In other words, don't look at how deep the wound goes, look at the depth of tissue actually removed. Cigna cites the example of a wound that extends to the muscular layer, but the physician only debrides infected subcutaneous tissue. You should code that service with 11042 (Debridement; skin, and subcutaneous tissue), not 11043 (... skin, subcutaneous tissue, and muscle). (See PBI, Vol. 4, No. 21, page 140 for more on coding debridements.)
 
And if the provider only removed "less defined devitalized (necrotic) tissue that is superficially lining the wound bed, commonly referred to as slough," you shouldn't use 11040-11044 at all, Cigna says. Instead, you should use 97601 (Removal of devitalized tissue from wound[s]; selective debridement without anesthesia ...). This code requires less "complex surgical skills" than the 11040 series, Cigna adds.
 
But if the provider only cleaned drainage, secretions or exudate from the wound, the service doesn't even meet the definition of debridement. You shouldn't bill any of these codes for such a service, Cigna states.
 
You should bill 97601 only once for a single session of wound care even if it includes multiple sites, but you can charge multiple units of 11040-11044 if there are multiple wound sites.
 
But Marcella Bucknam, HIM coordinator with Clarkson College in Omaha, Neb., says it's usually more appropriate to bill in the 11040-11044 series for debridements, even those performed by nonphysician practitioners. Originally, 97601 was intended to be billed by NPPs, but so many of these services are performed incident-to physician services that it makes more sense to bill using a physician code, Bucknam says.
 
"If the services are going to be billed incident-to under a physician number, it would be inappropriate to bill 97601 because it was never intended for physician use," Bucknam says. "If it's in their scope of license, there's no reason [NPPs] can't, and it's to their advantage" to bill 11040-11044, Bucknam adds. Also, it's very hard to justify 97601 without really terrific documentation.