Wiki Coding wound care 11042 Debridement, SubQ and add on code 11045 with over 40 cm debri

[kimaez]

I code and bill for a doctor who does wound care. When the dr. debride's multiple areas and some can be large areas also. Medicare usually will pay for up to 12 units, but just recently medicare is not wanting to pay for the first add on code, saying that the modifier is missing or incorrect. When have we needed to use a modifier on the first add on code. I have always be told only use modifier -76 on an add on code when dr. has done large amounts as in example below.


For this question my dr. has debrided 69.18 cm between multiple wounds, I usually code 11042 for the first 20 cm, and use add on code 11045 for next 20, another 11045-76, and I repeat as need up to about 12 units. With large areas I will use 3 or 4 units per code up to 12 total

 

[thomas7331]

You should not need to use a modifier for additional units of an add-on code, and this is not a repeat procedure, so modifier 76 is not really appropriate any.

For 69.18 sq cm, use 11042 X 1 and 11045 X 3. For very large areas, if your unit value on 11045 exceeds the MUE maximum for the payer, you will just have to submit your documentation for review in order to get payment - I know it used to be possible in the past to bypass MUE edits using modifiers, but that is generally no longer the case.

 

[kimaez]

Thank you.