Wiki Debridement Coding Clarification

[katecabrini]

Does anyone have clarification on when the provider provides pre and post debridement measurements but documents that “ _____ % of the wound was debrided" is it acceptable to use the post debridement measurements for coding or is this practice acceptable at all? I realize pre, post and actual is preferred, but some Providers prefer to utilize a percentage.

 

[Kristen Bensel]

It would depend on the type of debridement and payer, in my opinion.
For example for CPT 11042 Medicare is very specific that they require in the documentation the Pre and Post debridement measurements in addition to other documentation. If part of that is missing, then it wouldn't be correct to report the CPT for the debridement. I was taught that it is inappropriate to bill for procedures when all of it isn't documented correctly before the note is signed. Better to not bill it than to bill and have the payer request chart notes and find you billed for services not supported.
I have tried to find information regarding so support the missing information being added in an addendum being ok, but have not been able to find anything that I am comfortable with.