Eli's Rehab Report

Modifier -25 may be your key to bedsore pay for debridement,E/M visit

If your physiatrist treats one of the million patients with pressure ulcers annually, modifier -25 may be your key to reimbursement. But you should only append this modifier the physician performs debridement along with an E/M visit -- not if he simply performs dressing changes.

Pressure ulcers (ICD-9 707.0 ), also called bedsores, decubitus ulcers or pressure sores, describe any injury caused by unrelieved pressure that damages the skin and underlying tissue. Treatments vary according to the injury's size and severity, but they range from simple saline cleansing to debridement and surgery.

Physicians who evaluate rehabilitation patients often discover bedsores during their follow-up E/M visits. If the bedsore is in an early stage, the physiatrist might perform simple saline cleansing and apply topical antibiotics. In addition, physiatrists often evaluate the patient's nutritional status because undernourished patients do not respond to treatments as swiftly as those with complete diets. The E/M codes include topical antibiotic application, wound cleansing, and nutrition counseling; most insurers will not allow you to report these services separately if you perform an E/M visit on the same day.

Reimbursement tip: Many physiatrists treat pressure ulcers by removing necrotic tissue with sharp, mechanical, autolytic or enzymatic debridement. Depending on the number of layers that the physician debrides, you should report the appropriate code from the 11040-11044 series. For example, if he debrides skin, subcutaneous tissue and muscle, you should report 11043 (Debridement; skin, subcutaneous tissue, and muscle).

A physiatrist who performs debridement to alleviate pressure ulcers can bill both the E/M code and the debridement service by appending modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), as long as he documents a complete E/M visit and debridement.

"A misconception about modifier -25 is that you need a different diagnosis code than the procedure," says Lisa Center, CPC, quality coordinator with Freeman Health System in Joplin, Mo. Different diagnoses are not required when reporting E/M services on the same date as the debridement.

Don't overlook: If the reason for the physiatrist's visit is the debridement only, you should bill only the debridement service, not an E/M code, says Tammy Corbin-Young, LPN, HIA, CPC, CPC-H, an independent coding consultant in Dickson, Tenn. Make sure your physician performs a full E/M service before you look to modifier -25. "If this was a new wound that the physiatrist had never evaluated, then you should bill both the E/M service and the appropriate debridement code (11000-11044)."

If a physiatrist making rounds changes a patient's dressing but does not perform any debridement that day, you cannot bill for a dressing change alone. "There is a dressing change code (15852, Dressing change [for other than burns] under anesthesia [other than local]), but this code is for changes under anesthesia," Center says. "There is no separate code for dressing changes without a debridement done at the same time." Therefore, you should include this service in your physician's E/M service for that day.

Example: Apatient is at home recuperating from a traumatic brain injury. Her daughter brings her into your office, and the physiatrist sees that the patient's visiting home nurse has placed bandages on the patient's bedsores on her left leg and hip. The physician changes the dressings. Can he bill for the dressing supplies with HCPCS codes, or are these bundled?

Answer: "The practice can bill for the supplies, but the service of applying the bandages will most likely be bundled into any E/M code that the physician is reporting," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center in Absecon, N.J.

Many insurers will allow physical therapists, nurse practitioners or physician assistants to perform and bill for debridement under a physician's order.

Nonphysician practitioners should report 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) for "selective"debridement, which means that the practitioner removes the infected or necrotic skin using sharp-debridement techniques (such as cutting the dead skin with scissors).

In contrast, 97602 (... non-selective debridement, without anesthesia [e.g., wet-to-moist dressings, enzymatic, abrasion], including topical application[s], wound assessment, and instruction[s] for ongoing care, per session) describes gradually removing dead tissue from the patient during a series of visits. Physicians should not report 97601-97602.