Eli's Rehab Report

Find out if you should code the diabetes or ulcer first

If you're wondering how you're measuring up when it comes to reporting debridement codes, take five minutes to answer this simple two-question quiz.

Question 1: A patient with uncontrolled type II diabetes presents with an ulcer on his lower leg. The physiatrist debrides the wound through subcutaneous tissue and applies a dressing. For this scenario, you should code the debridement using:

A. 11041
B. 11042
C. 97597
D. 97598

Answer 1: B. You should report 11042 (Debridement; skin, and subcutaneous tissue), says John Bishop, PA-C, CPC, president of Bishop and Associates in Tampa, Fla. Why: When your physiatrist treats a wound, you should select the wound debridement code according to the depth to which the physician debrides the wound.

Remember, you shouldn't confuse the depth of debridement with the depth of the wound. Code 11042's definition includes "skin and subcutaneous tissue" but does not include the muscle and bone, Bishop says.

Heads up: The debridement code includes reimbursement for the dressing application, so you may not code separately for that service. "Routine dressing and supplies are bundled into the debridement code," Bishop says.

You shouldn't report 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) because these codes indicate that the physiatrist used a waterjet and that the patient was not under any kind of anesthesia, either local or general. These aspects are not part of the scenario.

Physiatrists don't normally report these codes. Primarily, physical therapists (PTs) or occupational therapists (OTs) use the newer wound care codes (97597-97598). "The only debridement code we use in our rehab setting is 97597," says Gregg Macek, director of rehabilitation at Barrington Orthopedic Specialists Ltd. in Hoffman Estates, Ill. "We employ mostly OTs and PTs, and most of the wounds they work on are minimal in size."

Think of it this way: "Only physiatrists and nonphysician practitioners (such as a physician assistant, PA, or nurse practitioner, NP) should use the surgical debridement codes (11040-11044) because these codes are for physician services," Bishop says.

Bonus: Don't forget to code for applying the negative pressure wound therapy (97605-97606) and any multi-layered compressive wraps, specialty dressings and splints and/or off-load contact casting if the physiatrists uses them during the service, Bishop says.

Question 2: The same patient from Question 1 has a neuropathic ulcer on his left lower leg. Your ICD-9 codes should be:

A. 707.1, 250.62
B. 250.62, 707.1
C. 707.12, 250.62
D. 250.62, 707.12

Answer 2: D. You should report 250.62 (Diabetes mellitus; diabetes with neurological manifestations; type II or unspecified type, uncontrolled) as the primary diagnosis and 707.12 (Ulcer of calf) for the secondary diagnosis. Note: The fifth digit "2" of 250.62 indicates the patient has type II, uncontrolled diabetes.

According to HIPAA's mandated ICD-9 guidelines, "When assigning codes for diabetes and its associated conditions, the code(s) from category 250 must be sequenced before the codes for the associated conditions. The diabetes codes and the secondary codes that correspond to them are paired codes that follow the etiology/manifestation convention of the classification." (For more information, see www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide05.pdf and scroll to page 8 for manifestation conventions).

Key: Look at your documentation to determine whether there is a causal relationship between the diabetes and the neuropathic ulcer. If the provider notes that the neuropathic ulcer is due to the diabetes, then you would need to code the diabetes code first and the manifestation code as secondary.

Not all neuropathic ulcers are due to diabetes, but the vast majority are. If the ulcers are due to the diabetes, the diabetes code would be the 250.8x series as the primary code rather than 250.6x. You may also use the 250.6x series for the patient's neuropathy complication.

Diabetic ulcers mean that you'll use a code from the 707.xx series for chronic skin ulcers. You should have selected 707.1 for a non-decubitus ulcer of the lower limb and then chosen the appropriate fifth digit according to the ulcer's location. In this case, the ulcer is on the calf.

Keep in mind: When coding ulcers, remember that the current coding system doesn't allow you to differentiate between a neuropathic ulcer and a neuroischemic ulcer. The ICD-9 listing under 707 says, "Code, if applicable, any causal condition first: ... diabetes mellitus (250.80-250.83)."

You should code all symptoms of the wound (such as infection, exudate, cellulitis, eschar, ischemia, etc.) along with the manifestations, Bishop says.