Surgical Debridement
CPT codes 11042–11047
Targeted Probe and Educate (TPE) Medical Review (MR) is currently being performed for Surgical Debridement CPT codes 11042–11047. According to the 2012 Comprehensive Error Rate Testing (CERT) report, the specialty of podiatry had a 7.4 percent error rate with a total projected improper payment amount of $131,795,384. The 2012 report also found that of the claims audited, 50.1 percent were insufficiently documented while 47.2 percent were incorrectly coded.
Previous education outreach results demonstrated that providers faced challenges in ensuring that their medical records incorporated all the aspects of the care rendered. Some obstacles were the Electronic Health/Medical Record) (E.H.R/E.M.R) systems utilized did not completely capture care components. Other barriers include a disconnect in what is documented and subsequently coded.
Wound debridements (CPT codes 11042–11047) are reported by depth of tissue that is removed and by surface area of the wound. These services may be reported for injuries, infections, wounds and chronic ulcers.
The correct coding of surgical debridement services (CPT codes 11042–11047) requires documentation of both the measurement of the wound surface (devitalized tissue) area after debridement and the depth of tissue that is removed. The measurement and documentation should be part of your standard operating procedures for surgical debridement. Establishing such a process will help you avoid claims submission errors, denials for insufficient documentation and potential overpayments.
In order to report CPT codes 11042–11047, the debridement must extend below the dermis. When the same depth of tissue is removed from different anatomic sites, the area of tissue removed is summed. When different depths of tissue are removed from the same anatomic site, only the deepest level of debridement is reported.
In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths.
Measurement and documentation should be part of your standard operating procedures. Developing a self-auditing tool such as a checklist will assist in determining what may be missing from the medical record. Providers should ensure the accuracy of their billing and review the documentation prior to responding to Additional documentation requests (ADRs).
A legible copy of the patient’s medical record along with all supporting documentation for debridement (CPT codes 11042–11047) would include:
- Tool used for debridement (curette, scalpel, other instruments)
- Frequency of surgical debridement
- Measurement of total devitalized tissue (wound surface) before and after surgical debridement
- Area and depth of devitalized tissue actually removed from wound (not just depth of wound)
- Blood loss and description of tissue removed
- Progress notes or procedure notes with a detailed description of the procedure
- Evidence of the progress of the wound’s response to treatment; this documentation must include at a minimum:
- Current wound volume (surface dimension and depth). Presence (and extent of) or absence of obvious signs of infection.
- Presence (and extent of) or absence of necrotic, devitalized or non-viable tissue
- Material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown
Medical Review Denial Reasons
- Need for service/item is not medically necessary (i.e., wound bed clean with percent granulation)
- No or incomplete documentation (no tool indicated, no description of tissue removed)
- Information was wrong for patient or wrong date of service
Billing Errors
- Provider billed in error
- CPT code 11043 reported when muscle and tendon are visible, but surgical debridement is not indicated
- Billing multiple "initial" CPT codes for the same wound site
*Please note that the recommended timeframe between treatments is one week. However, literature does support even more frequent debridement if tolerated by the patient and appropriate for the wound in question. Additional documentation to support this frequency must be made available.
CPT codes 11042–11047 are not cover the following services:
- Removal of necrotic tissue by cleansing or scraping (other than by scalpel or curette)
- Chemical applications and moist-to-dry or wet-to-dry dressings
- Dressing of small or superficial lesions
- Trimming of callus or Fibrinous material from the margin of an ulcer
- Paring or cutting of corns or non-plantar calluses
- Washing bacterial or fungal debris
- Removal of secretions and coagulation serum from normal skin surrounding an ulcer
- Incision and drainage of abscesses, debridement of mycotic nails, or debridement of burns
Self auditing your medical records can prevent billing errors and reduce medical necessity denials.
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