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Eli's Rehab Report

3 Tips Determine Your Diabetic Wound Care Codes

Published on Mon Mar 21, 2005

Selection depends on the depth of the debridement, not the depth of the wound

You're not alone if you're stumped when it comes to determining whether to report the new wound care codes (97597-97598) or the old reliables (11040-11044). These three expert tips unlock the secret to making the correct choice every time.

1. Lean What Makes 2 New Codes Different

CPT 2005 introduced two new wound care codes: CPT 97597 (Removal of devitalized tissue from wound[s], selective debridement, without anesthesia [e.g, high-pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], with or without topical application[s], wound assessment, and instruction[s] for ongoing care, may include use of a whirlpool, per session; 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). And deciding when these codes are more accurate than 11040-11044 is the cause of a lot of confusion.
 
The two new codes are similar to current debridement codes 11040-11044, but the new codes differ by specifically indicating a) the use of a waterjet and b) the patient is not under any kind of anesthesia, either local or general. Before deciding to report one of these codes, consider the following two questions:
 
1. Does the carrier allow your physician to code for this service? Not all carriers allow physicians to bill for 97597 and 97598. One Medicare carrier, Cigna, now has a local coverage determination (LCD) stating that doctors of podiatry, internal medicine, osteopathy and allied health professionals may bill these codes (if services provided match the code descriptor). Meanwhile, Florida carrier First Coast Service Options' policy states that only physical therapists, occupational therapists or enterostomal nurses may report these codes. So make sure to check your carrier's LCD policy carefully before submitting your claims.
 
Watch out: Private payers may not have these codes set up yet in their systems.
 
2. Which code set has higher RVUs? Although 97597-97598 report services similar to those of debridement code series 11040-11044, the latter codes have a higher RVU value, says Richard D. Odom, DPM, CPC, assistant professor in the department of surgery at Texas A&M's Health Science Center in Temple. See chart below of total nonfacility RVUs as reported by Ingenix:

   Code    RVU
   97597   1.29
   97598   1.64
   11041   1.58
   11042   2.22
   11043   6.05
   11044   7.91

Even though your carrier may allow you to report the new codes, the decision to do so will cost your bottom line.

2. Choose Ulcer Codes Based on Depth

 When your physician treats a wound, you should select the appropriate wound debridement code according to the depth to which the physician debrides the wound. Remember not to confuse the depth of debridement with the depth of the wound. Here's how the five codes break down depth of debridement:
 

  • 11040 - Debridement; skin, partial thickness
     
  • 11041 - ... skin, full thickness
     
  • 11042 - ...skin, and subcutaneous tissue
     
  • 11043 - ...skin, subcutaneous tissue, and muscle
     
  • 11044 - ...skin, subcutaneous tissue, muscle, and bone.
     
    You should use these codes when your physician treats a skin ulcer. Foot and ankle specialists and orthopedic surgeons may use these codes for chronic or nonhealing skin ulcers that can occur from casts rubbing a patient's skin or prolonged periods of bed rest. A physiatrist may use this code for a diabetes patient.
     
    For example: A patient with uncontrolled type II diabetes presents with an ulcer on his lower leg. The physiatrist debrides the wound through the subcutaneous tissue and applies a dressing. For this scenario, you would code 11042 for the debridement. The dressing application is included in the debridement, so you may not code separately for that service.
     
    Debridement don't:     For many Medicare carriers, there are specific services that you may not bill as debridements. For example, Cigna Medicare's policy states that reporting 11040-11044 "is not appropriate for the following services: washing bacterial or fungal debris from lesions, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement."

    3. Be Careful With Your Ulcer Diagnoses

    When reporting diabetic ulcer debridement to carriers, make sure the diagnosis code is appropriate for the procedure, says Suzan Hvizdash, BSJ, CPC, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh.
     
    For example: The diabetic patient from the previous example has a neuropathic ulcer on his lower leg.
     
    You should code for diabetic ulcers using the 707.xx  series for chronic skin ulcers. Select 707.1 for a non-decubitus ulcer of the lower limb, and then choose the appropriate fifth digit according to the ulcer's location. In this case, you would choose 707.12 (... ulcer of calf). According to Medicare carrier HGSA, 707.12 is a covered diagnosis for CPT code 11042.
     
    Tip: When coding ulcers, remember that the current coding system does not allow you to differentiate between a neuropathic ulcer and a neuroischemic ulcer, Odom says. It's an ulcer, regardless of what caused it, he says.
     
    Correct order matters: Incorrectly sequencing diabetes and ulcer diagnosis codes is a common wound debridement coding error, says Renee Collington, CPC, of the department of surgery vascular division at UPMC Presbyterian-Shadyside in Pittsburgh.
     
    Coders often list the diabetes diagnosis code (250.xx) first, followed by the ulcer code, such as 707.12. You should always report the ulcer code first and the diabetes code second, Collington says. Carriers want your primary diagnosis code to reflect the acute condition your physician treated during the visit. 
     
    Example: In the case of the diabetes patient discussed above, you would code the ulcer (707.12) as the primary diagnosis, and then report the patient's diabetic neuropathy with 250.62 (Diabetes mellitus; diabetes with neurological manifestations; type II or unspecified type, uncontrolled). The fifth digit "2" indicates the patient has type II, uncontrolled diabetes.
     
    Take note: You only indicate the site of a wound with the 707 series diagnosis codes, but wound size and depth are also important for documentation. If your physician fails to document all three pieces of information in the medical record, he may make choosing the correct-level debridement code difficult for you, Hvizdash says.

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