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Coding For Ulcer DebridementJeffrey D. Lehrman, DPM, FASPS, MAPWCAAPMA Coding CommitteeExpert Panelist, CodinglineAPMA MACRA Task ForceFellow, American Academy of Podiatric Practice ManagementBoard of Directors, ASPSBoard of Directors, APWCATwitter: @DrLehrman

11040 / 11041 Deleted from CPT Do not use them Ever Replaced by 97597 / 97598 January 1, 2011

97602 Removal of devitalized tissue from wound(s), nonselective debridement, without anesthesia (eg, wet-tomoist dressings, enzymatic, abrasion) including topicalapplication(s), wound assessment, and instruction(s)for ongoing care, per session Non sharp debridement For nurses / facility No RVU assignment for physician

Code choice based ondeepest depth to which youdebride Dermis SubQ Muscle / Fascia Bone

97597 Debridement of open wound to level ofepidermis/dermis total wound surface area less than orequal to 20 square centimeters Debridement defined as: high pressure waterjet with or without suction sharp selective debridement with scissors, scalpel, andforceps Debridement should involve removal of: fibrin, devitalized epidermis and/or dermis, exudate,debris, biofilm

Examples Remember TOTAL Wound Surface Area One ulcer 4cm x 4cm debrided to dermis: 97597 one unit Two ulcers: first 2cm x 2cm, second 4cm x 4cm bothdebrided to dermis 97597 one unit Three ulcers: 2cm x 2cm, 3cm x 2cm, 2cm x 2cm allthree debrided to dermis 97597 one unit

97598 Add-on code to 97597 To be used if wound over 20 sq. cm Debridement of open wound to level of epidermis /dermis each additional 20 square centimeters Used WITH 97957 No 51 modifier on 97598 with 97597 Never to be used alone

Examples One ulcer 5 x 5 sq. cm 97597 one unit 97598 one unit Two ulcers: first 4 x 4, second 4 x 3 sq. cm 97597 one unit 97598 one unit

Examples cont Two ulcers: first 5 x5, second 5 x 4 97597 one unit 97598 2 units One ulcer 75 sq. cm 97597 one unit 97598 3 units

97597/97598 Fall under Medicare consolidated billing Will not get paid if patient is in a facility on aMedicare Part A stay Can try to contract with facility .good luck!

11042/11045 11042: Debridement to subcutaneous tissuefirst 20sq. cm or less total 11045: Add-on code: Debridement to subQeach additional 20sq. Cm. Includes epidermis and dermis with it

11043/11046 11043: Debridement to muscle/fascia first 20sq.cm or less total 11046: Add-on code: Debridement tomuscle/fascia each additional 20sq. Cm. Includes epidermis and dermis and subQ with it Big jump in reimbursement from 11042 Submit Pathology!

11044/11047 11044: Debridement to bone first 20sq. cm orless total 11047: Add-on code: Debridement to boneeach additional 20sq. Cm. Includes epidermis and dermis and subQ andmuscle/fascia with it Submit Pathology!

All options together 97597 up to 20 sq. cmEpidermis/Dermis 97598 each addl. 20 sq cm 11042 up to 20 sq. cm.SubQ 11045 each addnl. 20 sq. cm 11043 up to 20 sq. cm.Muscle/Fascia 11046 each addnl. 20 sq. cm 11044 up to 20 sq. cm 11047 each addnl. 20 sq. cmBone

Choose correct code Code based on depth of tissue actuallydebrided, not the depth of the wound Sq. cm. used is amount of tissue debrided, notthe size of the ulcer

Examples Ulcer is 6cm x 5cm to depth of dermis and youdebride 4cm x 4cm of tissue to dermis: 97597 Ulcer is 6cm x 6cm to depth of bone and youdebride 4cm x 3cm of it to subQ 11042

Two ulcers If at same depth, one code for total sq. cm.debrided at that depth If debrided at different depths then can use twocodes

Examples One ulcer debride 2cm x 2cm to dermis andanother debride 6cm x 6cm to muscle.97597 – 59 mod1104311046

Included in debridement Dressing change Local care training Topicals applied

Novitas 2017 Part B PhysicianFee ScheduleNon-Facility 97597: 81.73 11042: 126.93 11043: 249.05 11044: 343.86 All have Zero day global

Check Your LCD 11043 / 11044: Need to send pathology? 11043 / 11044: Place of service?

Documentation Different plans and different LCD’s mayhave different requirements. You are responsible to know We’re talking about outpatientdocumentation requirements

Some LCDs Require Document medical necessity of debridement AKA whyyou are doing it . Decrease risk of infection Promote healing Limb salvage Medical Diagnosis Anesthesia, if used

Some LCDs Require Wound size(s) in sq. cm. Depth of wound Square cm. of tissue debrided Depth of tissue debrided Drainage Color Absence / presence of necrotic tissue

Some LCDs Require Vascularity Op Report Patient specific goals Wound better or worse?

Some LCDs Require Texture Location of ulcer Temperature Presence or absence of Condition ofSurrounding Tissue Presence or absence ofinfectionUndermining/Tunneling

Some LCDs Require Instrument used Dressings used Immediate post-debridement care Instructions Methods of offloading Complicating factors/Comorbidities

Photograph?

Coding For Ulcer DebridementJeffrey D. Lehrman, DPM, FASPS, MAPWCAAPMA Coding CommitteeExpert Panelist, CodinglineAPMA MACRA Task ForceFellow, American Academy of Podiatric Practice ManagementBoard of Directors, ASPSBoard of Directors, APWCATwitter: @DrLehrman

DIAGNOSIS CODING

Ulcer options L97- Non-pressure chronic ulcer oflower limb, not elsewhereclassified Diabetic foot ulcers go here! L89- Pressure ulcer

Stasis ulcer options I83.0- Varicose veins of lowerextremities with ulcer I83.2- Varicose veins of lowerextremities with both ulcerand inflammation

Arterial ulcer options I70.23- Atherosclerosis of nativearteries of right leg with ulceration I70.24- Atherosclerosis of nativearteries of left leg with ulceration I70.26- Atherosclerosis of nativearteries of extremities with gangrene

“Wound” versus “Ulcer” S91.0- Open wound of ankle S91.1- Open wound of toe without damage to nail S91.2- Open wound of toe with damage to nail S91.3- Open wound of foot

Ulcer options L97- Non-pressure chroniculcer of lower limb, notelsewhere classified Diabetic foot ulcers go here! L89- Pressure ulcer

What type of ulcer is it? Pressure Ulcer ulcer from pressure Diabetic Foot Ulcer ulcer on diabetic patient Arterial Ulcer ulcer from lack of blood"Diabetic Ulcers v Pressure Ulcers; So, What Do You Call It?",Arthur Stone, DPM and Mary Sieggreen, MSN,CNS,NP,CVN)from the National Pressure Ulcer Advisory Panel

DFU CodingType 2 diabetic patient with a chronic diabetic leftlateral midfoot ulcer with necrosis of muscle. Thepatient takes insulin on a daily basis.

L97.423 Non-pressure chroniculcer of left heel andmidfoot with necrosis ofmuscle

E11.621 Type 2 diabetes mellituswith foot ulcer

DFU CodingType 2 diabetic patient with chronic diabetic left foot lateralmidfoot ulcer with necrosis of muscle. The patient takes insulinon a daily basis. E11.621 Type 2 diabetes mellitus with left foot ulcer Z79.4Long term (current) use of insulin L97.423 Non-pressure chronic ulcer of left heel and midfootwith necrosis of muscle

DFU DocumentationICD 9Chronic Midfoot ulcer in Type 2diabeticICD 10Chronic, non-pressure left midfoot ulcerwith necrosis of muscle in a type 2diabetic with long term insulin use

Arterial Ulcers

PAD I70.231 Atherosclerosis of native arteries of right leg with ulcerationof thigh I70.232 Atherosclerosis of native arteries of right leg with ulcerationof calf I70.233 Atherosclerosis of native arteries of right leg with ulcerationof ankle I70.234 Atherosclerosis of native arteries of right leg with ulcerationof heel and midfoot I70.235 Atherosclerosis of native arteries of right leg with ulcerationof other part of foot Use additional code to identify severity of ulcer (L97.-)

PAD I70.241 Atherosclerosis of native arteries of left leg with ulceration ofthigh I70.242 Atherosclerosis of native arteries of left leg with ulceration ofcalf I70.243 Atherosclerosis of native arteries of left leg with ulceration ofankle I70.244 Atherosclerosis of native arteries of left leg with ulceration ofheel and midfoot I70.245 Atherosclerosis of native arteries of left leg with ulceration ofother part of foot Use additional code to identify severity of ulcer (L97.-)

Gangrene I70.261 Atherosclerosis of native arteries of extremities withgangrene, right leg I70.262 Atherosclerosis of native arteries of extremities withgangrene, left leg I70.263 Atherosclerosis of native arteries of extremities withgangrene, bilateral legs Use additional code to identify the severity of any ulcer(L97.-, L98.49-), if applicable

89 year old non-diabetic nursing homepatient with unstageable right heelpressure ulcer

L89.610Pressure ulcer of right heel,unstageable

Thank You!!

Coding For Ulcer DebridementJeffrey D. Lehrman, DPM, FASPS, MAPWCAAPMA Coding CommitteeExpert Panelist, CodinglineAPMA MACRA Task ForceFellow, American Academy of Podiatric Practice ManagementBoard of Directors, ASPSBoard of Directors, APWCATwitter: @DrLehrman

Resources Fife, C.E., MD, FAAFP, CWS. The debridement bridement-dilemmareturns?page 4, National Government Services. National Government ServicesLCD for Debridement CD L27373.htm, Just Coding News. (August 8, 2012). Differentiate between typesof wound debridement. JustCoding News: Outpatient Novitas Local Coverage Determination (LCD):Wound Care (L35139) ils/lcddetails.aspx?LCDId 35139&ver 40&CntrctrSelected 324*1&Cntrctr 324&s 45&DocType Active&bc AggAAAIAIAAAAA%3d%3d&

Resources Kesselman, P., DPM. (September, 2013). Wound care billingupdate, Podiatry Management pg 53-59 LeGrand, M., RN, MA CCS-P, CPC., Changes in reporting /jun11/managing2.asp CGS Medicare. (May 9, 2012). Documenting surgical debridementservices – Measurements 012/0512/cope18819.html, Noridian Medicare, Wound care and debridement – Provided byphysician, NPP or as incident-to oranto/viewnews.cgi?id EFFZFZyyEpAJGDJCxK&tmpl parta viewnews&style part ab viewnews

I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot I70.245 Atherosclerosis of native arteries of left leg with .