Automated Clinical/Wound Debridement Services

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Wound Debridement Services

Medicare will consider Wound Debridement Services medically reasonable and necessary under the following circumstances:

Utilization Guidelines:

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• Coverage for wound care on a continuing basis for a given wound in a given patient is contingent upon evidence documented in the patient's medical record that the wound is improving in response to the wound care being provided.

◦ It is neither reasonable nor medically necessary to continue a given type of would care if evidence of wound improvement cannot be shown.

• Surgical debridement codes (11042-11047), as performed by physicians and qualified non-physician practitioners licensed by the state to perform those services, are reported by depth of tissue removed and by surface area of the wound.

• These codes can be very effective but represent extensive debridement, often painful to the patient, and could require complex, surgical procedures and sometimes require the use of general anesthesia.

• Documentation for surgical debridement procedures should include the indications for the procedure, the type of anesthesia if and when used, and the narrative of the procedure thatdescribes the wounds, as well as the details of the debridement procedure itself.

• The CPT code selected should reflect the level of debrided tissue (e.g. Skin, subcutaneous tissue, muscle and/or bone), not the extent, depth, or grade of the ulcer or wound.

◦ For example, CPT code 11042 defined as "Debridement, subcutaneous tissue" should be used if only necrotic subcutaneous tissue is debrided, even though the ulcer or wound might extend to the bone. In addition, if only fibrin is removed, this code wouldnot be billed.

• Active Wound Care Management

◦ Debridement is indicated whenever necrotic tissue is present on an open wound.

◦ Debridement may also be indicated in cases of abnormal wound healing or repair.

◦ Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue.

◦ This procedure includes wound assessment; debridement; application of ointments, creams, sealants, and other wound coverings; and instructions for ongoing care.

◦ It should be billed no more than once per day, regardless of the number of wounds.

• Surgical debridement will be considered as "not medically necessary" when documentation indicates the wound is without infection, necrosis, or nonviable tissues and has pink to red granulated tissue.

◦ Evidence of improvement includes, but is not limited to, measurable changes in at least some of the following:

▪ Drainage (color, amount, consistency)

▪ Inflammation

▪ Swelling

▪ Pain

▪ Wound dimensions (diameter, depth, tunneling)

▪ Granulation tissue

▪ Necrotic tissue/slough

• Such evidence must be documented with each visit.

• A wound that shows no improvement after 30 days requires a new approach, which may include a reassessment, by a qualified professional, of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new plan of care or treatment method.

• The use of a sharp instrument does not necessarily substantiate the performance of surgical excisional debridement.

◦ Unless the medical record shows that a surgical excisional debridement has been performed, debridements should be coded with either selective or non-selective codes (97597, 97598, or 97602).

• The requirements for reasonable and necessary service(s) include safe and effective debridement methods most appropriate to the type of wound, furnished in the appropriate setting, and ordered and/or performed by qualified personnel.

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

◦ When services are performed in excess of established parameters, they may be subject to review for medical necessity.

• The appropriate interval and frequency of debridement depends on the individual clinical characteristics of patients and the extent of the wound.

◦ Reduction of pressure and/or control of infection will facilitate healing and may reduce the need for repeated debridement services.

◦ The treatment plan for a patient who requires frequent repeated debridement should bereevaluated to ensure that pressure reduction and infection control have been adequately addressed.

• Debridement services are not considered to be medically necessary when performed more frequently than once a week.

◦ The rationale and medical justification for more frequent services must be clearly documented in the medical record.

◦ If the debridement of chronic ulcers require more than eight total services for any of the debridement codes listed in the LCD (CPT codes 11000-97598), the rationale and medical justification for this utilization, on a given day or over time, must be specifically addressed in the medial record.

Limitations:

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• CPT code 11001 is not appropriate for debridement of a localized amount of tissue normally associated with a circumscribed lesion.

◦ Examples of this are

▪ Ulcers.

▪ Furuncles.

▪ Localized skin infections.

• It would not be expected that an individual wound would be repeatedly debrided of skin and subcutaneous tissue because these tissues do not regrow very quickly.

• The following services are not considered to be wound debridement:

◦ Removal of necrotic tissue by cleansing, scraping (other than by a scalpel or a curette), chemical application, and wet-to-dry dressing.

◦ Washing bacterial or fungal debris from lesions.

◦ Removal of secretions and coagulation serum from normal skin surrounding an ulcer.

◦ Dressing of small or superficial lesions.

◦ Removal of fibrinous material from the margin of an ulcer.

◦ Paring or cutting of corns or non-plantar calluses.

▪ Skin breakdown under a dorsal corn that begins to heal when the corn is removed and shoe pressure eliminated is not considered an ulcer and does not require debridement unless there is extension into the subcutaneous tissue.

◦ Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, or destruction of warts.

▪ Providers should report these procedures, when they represent covered, reasonableand necessary services, using appropriate CPT or HCPCS codes.

ICD10CM Codes that support medical necessity: (Please check all that apply)

A48 Other bacterial diseases, not elsewhere classified

B35 Dermatophytosis

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(Includes) favus infections due to species of Epidermophyton, Micro-sporum and Trichophyton tinea, any type except those in B36.-

B35.0XXX Tinea barbae and tinea capitis

B35.1XXX Tinea unguium

B35.2XXX Tinea manuum

B35.3XXX Tinea pedis

B35.4XXX Tinea corporis

B35.5XXX Tinea imbricata

B35.6XXX Tinea cruris

B35.8XXX Other dermatophytoses

B35.9XXX Dermatophytosis, unspecified

I70 Atherosclerosis

I73 Other peripheral vascular diseases

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(Excludes Type 2) chilblains (T69.1) frostbite (T33-T34) immersion hand or foot (T69.0-) spasm of cerebral artery (G45.9)

I73.9XXX Peripheral vascular disease, unspecified

I83 Varicose veins of lower extremities

I96.XXXX Gangrene, not elsewhere classified

K62 Other diseases of anus and rectum

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(Includes) anal canal

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(Excludes Type 2) colostomy and enterostomy malfunction (K94.0-, K94.1-) fecal incontinence (R15.-) hemorrhoids (K64.-)

K62.6XXX Ulcer of anus and rectum

L01 Impetigo

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(Excludes Type 1) impetigo herpetiformis (L40.1)

L01.0 Impetigo

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(Inclusion term) Impetigo contagiosa Impetigo vulgaris

L01.00XX Impetigo, unspecified

L01.01XX Non-bullous impetigo

L01.02XX Bockhart's impetigo

L01.03XX Bullous impetigo

L01.09XX Other impetigo

L01.1XXX Impetiginization of other dermatoses

L02 Cutaneous abscess, furuncle and carbuncle

L03 Cellulitis and acute lymphangitis

L08 Other local infections of skin and subcutaneous tissue

L08.0XXX Pyoderma

L08.8 Other specified local infections of the skin and subcutaneous tissue

L08.81XX Pyoderma vegetans

L08.89XX Other specified local infections of the skin and subcutaneous tissue

L08.9XXX Local infection of the skin and subcutaneous tissue, unspecified

L23 Allergic contact dermatitis

L24 Irritant contact dermatitis

L25 Unspecified contact dermatitis

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(Excludes Type 1) allergic contact dermatitis (L23.-) allergy NOS (T78.40) dermatitis NOS (L30.9) irritant contact dermatitis (L24.-)

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(Excludes Type 2) dermatitis due to ingested substances (L27.-) dermatitis of eyelid (H01.1-) eczema of external ear (H60.5-) perioral dermatitis (L71.0) radiation-related disorders of the skin and subcutaneous tissue (L55-L59)

L25.0XXX Unspecified contact dermatitis due to cosmetics

L25.1XXX Unspecified contact dermatitis due to drugs in contact with skin

L25.2XXX Unspecified contact dermatitis due to dyes

L25.3XXX Unspecified contact dermatitis due to other chemical products

L25.4XXX Unspecified contact dermatitis due to food in contact with skin

L25.5XXX Unspecified contact dermatitis due to plants, except food

L25.8XXX Unspecified contact dermatitis due to other agents

L25.9XXX Unspecified contact dermatitis, unspecified cause

L30 Other and unspecified dermatitis

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(Excludes Type 2) contact dermatitis (L23-L25) dry skin dermatitis (L85.3) small plaque parapsoriasis (L41.3) stasis dermatitis (I83.1-.2)

L30.9XXX Dermatitis, unspecified

L56 Other acute skin changes due to ultraviolet radiation

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(Use additional code) code to identify the source of the ultraviolet radiation (W89, X32)

L56.4XXX Polymorphous light eruption

L56.8XXX Other specified acute skin changes due to ultraviolet radiation

L58 Radiodermatitis

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(Use additional code) code to identify the source of the radiation (W88, W90)

L58.0XXX Acute radiodermatitis

L58.1XXX Chronic radiodermatitis

L58.9XXX Radiodermatitis, unspecified

L59 Other disorders of skin and subcutaneous tissue related to radiation

L88.XXXX Pyoderma gangrenosum

L89 Pressure ulcer

L92 Granulomatous disorders of skin and subcutaneous tissue

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(Excludes Type 2) actinic granuloma (L57.5)

L92.3XXX Foreign body granuloma of the skin and subcutaneous tissue

L92.8XXX Other granulomatous disorders of the skin and subcutaneous tissue

L97 Non-pressure chronic ulcer of lower limb, not elsewhere classified

L98 Other disorders of skin and subcutaneous tissue, not elsewhere classified

M72 Fibroblastic disorders

M86 Osteomyelitis

N49 Inflammatory disorders of male genital organs, not elsewhere classified

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(Use additional code) code (B95-B97), to identify infectious agent

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(Excludes Type 1) inflammation of penis (N48.1, N48.2-) orchitis and epididymitis (N45.-)

N49.1XXX Inflammatory disorders of spermatic cord, tunica vaginalis and vas deferens

N49.2XXX Inflammatory disorders of scrotum

N49.3XXX Fournier gangrene

N49.8XXX Inflammatory disorders of other specified male genital organs

N49.9XXX Inflammatory disorder of unspecified male genital organ

N50 Other and unspecified disorders of male genital organs

•

(Excludes Type 2) torsion of testis (N44.0-)

N50.1XXX Vascular disorders of male genital organs

S01 Open wound of head

S08 Avulsion and traumatic amputation of part of head

S11 Open wound of neck

S21 Open wound of thorax

S31 Open wound of abdomen, lower back, pelvis and external genitals

S38 Crushing injury and traumatic amputation of abdomen, lower back, pelvis and external genitals

S41 Open wound of shoulder and upper arm

S48 Traumatic amputation of shoulder and upper arm

S51 Open wound of elbow and forearm

S58 Traumatic amputation of elbow and forearm

S61 Open wound of wrist, hand and fingers

S68 Traumatic amputation of wrist, hand and fingers

S71 Open wound of hip and thigh

S78 Traumatic amputation of hip and thigh

S81 Open wound of knee and lower leg

S88 Traumatic amputation of lower leg

S91 Open wound of ankle, foot and toes

S98 Traumatic amputation of ankle and foot

T20 Burn and corrosion of head, face, and neck

T21 Burn and corrosion of trunk

T22 Burn and corrosion of shoulder and upper limb, except wrist and hand

T23 Burn and corrosion of wrist and hand

T24 Burn and corrosion of lower limb, except ankle and foot

T25 Burn and corrosion of ankle and foot

T81 Complications of procedures, not elsewhere classified

T87 Complications peculiar to reattachment and amputation

T87.4 Infection of amputation stump

T87.40XX Infection of amputation stump, unspecified extremity

T87.41XX Infection of amputation stump, right upper extremity

T87.42XX Infection of amputation stump, left upper extremity

T87.43XX Infection of amputation stump, right lower extremity

T87.44XX Infection of amputation stump, left lower extremity

T87.9XXX Unspecified complications of amputation stump

Documentation Requirements:

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• Medical record documentation maintained by the performing provider must clearly indicate the medical necessity of the service being billed.

◦ The medical record must include the following information and be available upon request:

▪ An operative note or procedure note for the debridement service(s).

• This note should describe the anatomical location treated, the instruments used, anesthesia used if required, the type of tissue removed from the wound, the depth and area of the wound and the immediate post-op care and follow-up instructions.

▪ Identification of the wound location, size, depth and stage by description and may include a drawing or photograph.

▪ A description of the type(s) of tissue involvement, the severity of tissue destruction, undermining or tunneling, necrosis, infection or evidence of reduced circulation.

▪ A pathology report when billing for the debridement procedure described by CPT code 11044.

• In addition, except for patients with compromised healing due to severe underlying debility or other factors, documentation in the medical record must show:

◦ The status of the wound is such that the treatment is expected to make a significant practical improvement in the wound in a reasonable and generally predictable period of time.

◦ There is an expectation that the treatment will substantially affect tissue healing and viability, reduce or control tissue infection, remove necrotic tissue or prepare the tissue for surgical management.

◦ The patient's expected restoration potential must be significant in relation to theextent and duration of treatment required in achieving this potential.

◦ If wound closure is not a goal, then the expectation is to optimize recovery and establish an appropriate non-skilled maintenance program.

• Active wound care management performed by a physical or occupational therapist must be performed under a certified plan of care as any other therapy service outlining specific goals, duration, frequency, modalities, an anticipated endpoint, and other pertinent factors as they may apply.

◦ Departure from this plan must be documented.

Treatment Logic:

The following treatment logic is considered:

Scientific Basis Of Treatment And Bibliography:

The treating physician does not consider this procedure experimental and has included the following sources of information as a basis for the treatment decisions that are in the best interest of the patient.

Sources of Information and Basis for Decision:

FCSO reference LCD numbers - L28776, L29128, L29146

Ayello, E., & Cuddigan, J. (2004). Debridement: Controlling the necrotic/cellular burden.Advances in Skin & Wound Care, 17:66-78.

Black, J., Baharestani, M., Cuddigan, J., Dorner, B., Edsberg, L., Langemo, D., & et al. (2007). National pressure ulcer advisory panel's updated pressure ulcer staging system. Dermatology Nursing. 19(4): 343-349.

Choucair, M. M., Fivenson, D. P. (2001). Leg ulcer diagnosis and management. Retrieved March 19, 2002 from http://homeconsult.com/das/article/body/1/jorg=journal&source=MI&sp=12040563&sid This reference provided information surrounding appropriate diagnoses criteria.

CPT Changes: An Insider's View - 2005, 2008, 2011

Debridement. (2004). Body1, Inc. Retrieved October 6, 2008 from http://www.wounds1.com/procedure20.cfm/19

Deery, H. G., & Sangererozan, J. A. (2001). Saving the diabetic foot with special reference to the patient with chronic renal failure. Retrieved March 19, 2002 from http://home.mdconsult.com/das/article/body/1/jorg=journal&source=MI&sp=11974766&sid This reference provided definitions and indications for wound management.

Fife, C. (2008). The debridement predicament. Retrieved October 6, 2008 from: http://www.intellicure.com/News/2008_01-02_Pulse/debridement _predicament.htm

Lewis, R., Whiting, P., ter Riet, G., O'Meara S., & Glanville, J. (2001). A rapid and systemic review of the clinical effectiveness and cost-effectiveness of debriding agents intreating surgical wounds healing by secondary intention. Retrieved March 19, 2002 from http://home.mdconsult.com/das/citation/body/jorg=journal&source=MI&sp=11892394&sid This reference provided expectations of treatments for wounds.

Other Medicare Contractors' LCDs.

Paquette, D., & Fatanga, V. (2002). Leg ulcers. Retrieved March 19, 2002 from http://home.mdconsult.com/das/article/body/1/jorg=journal&source=&sp=12074980&sid This reference provided descriptions and treatments for leg wounds.

Salcido, R., & Popescu, A. (2006). Pressure ulcers and wound care. Retrieved October 1, 2008 from : http://www.emedicine.com/pmr/TOPIC179.HTM

Schaum, K. (2006). Newly funded selective and non-selective debridement CPT codes: Impacton hospital-owned outpatient wound care departments. Healthpoint, Inc. Retrieved October 1, 2008 from: http://www.woundsresearch.com/docs/Healthpoint_August.pdf

Stillman, R. (2008). Diabetic ulcers. Retrieved October 2, 2008 from : http://www.emedicine.com/med/TOPIC551.HTM

Suzuki, K. & Cowan, L. (2009). Current concepts in wound debridement. Podiatry Today, 22(7) July 1.

Tatsioni, A., Balk, E., O'Donnell, T., Lau, J. (2007). Usual care in the management of chronic wounds: A review of the recent literature. Journal of the American College of Surgeons, 205(4).

Ulcer. (2008). New World Encyclopedia. Retrieved October 2, 2008 from http://www.newworldencyclopedia.org/entry/Ulcer?oldid=683900

Valencia, I., Falabella, A., Kirsner, R. S., & Eaglstein, W. E. (2001). Chronic venous insufficiency and venous leg ulceration. Retrieved March 19, 2002 from http:/home.mdconsult.com/das/article/body/1/jorg=journal&source=MI&sp=11546251&sid This reference defined and discussed debridement and other treatment modalities.

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

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Review Transcript

Last Update
05/18/2022 17:28 (R1.3)