COMPASS POINT: Arm yourself with a deeper understanding of what goes into code selection and compliant documentation for various types of debridement.
Debridement is often heavily scrutinized by various auditors, government agencies and insurers. Let’s dive into a discussion about documentation requirements for debridement. This article will not focus, however, on burn debridement or burn excision codes.
Current Procedural Terminology® (CPT) Codes
The specific set of codes that we will be using to discuss debridement are as follows1:
11042: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less
11043: Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less
11044: Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less
11045: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure)
11046: Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure)
11047: Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure)
97597: Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less
97598: Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure)
In my experience, some coverage policies state that debridement of fibrin and biofilm are considered part of an Evaluation and Management (E/M) visit. If you look carefully at the codes 97597 and 97598, however, you will note that “Debridement of … fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm” is clearly included in those code descriptions.1
Understanding the Differences in the Code Categories
Debridement (CPT 11042–11047). Selection of debridement codes are based on the actual type of tissue removed from the wound as well as the surface area of the wound. Surgical debridement includes going slightly beyond the point of visible necrotic tissue until viable bleeding tissue is encountered in most cases. The use of a sharp instrument does not necessarily substantiate the performance of surgical debridement.1
The medical record should illustrate the performance of a surgical debridement with tissue removed, such as subcutaneous tissue, muscle, or bone down to healthy bleeding tissue. The most important point to remember is to code the depth of tissue removed, not the depth of tissue the provider can see. For example, you may see bone in the base of the wound during the procedure; however, if there was only subcutaneous tissue removed, then the debridement would be coded to subcutaneous, not to bone.
Selective Debridement (CPT 97597 and 97598). Selective debridement refers to the removal of specific, targeted areas of devitalized tissue or tissue that limits healing from a wound along the margin of viable tissue. Occasional bleeding and pain may occur. Be careful of terminology as many clinicians use different terminology for the same procedures. For example, “conservative sharp debridement” is a minor procedure that requires no anesthesia and is performed on an outpatient basis. The qualified health professional may use a scalpel, scissors, and/or tweezers/forceps and only removes clearly identified necrotic/devitalized tissue. Generally, no bleeding is associated with this procedure. As a reminder, simply stating sharp debridement does not put the debridement into the 11042–11047 series. You will note that sharp selective debridement with scissors, scalpel or forceps is in the code description of 97597.1
Documentation Elements to Include
Each of the below points should be part of one’s debridement documentation. Check these bullet points against your own documentation to assess your compliance and identify areas to improve.1 You may also use the Internal Audit Debridement Documentation Tool (see related content at the bottom of this page) to complement this personal assessment.
- For each wound, describe any previous treatments and the response to the treatments. Remember: each procedure must be deemed medically necessary.
- Is the diagnosis reported for that encounter on the list of ICD-10-CM codes applicable to the policy?
- Describe the etiology of the wound and how the underlying cause is being addressed.
- On every debridement procedure, describe the wound in terms of length x width x depth. Record pre- and post-debridement measurements. Grid drawings and/or photos are recommended.
- Describe the wound composition in detail such as percent of granulation tissue, percent of devitalized tissue, and percent of other tissue type(s) totaling 100% of the wound accounted for.
- Is there evidence of infection, undermining, or tunneling?
- Document exact types of tissue removed from the wound such as epidermis, dermis, subcutaneous, muscle and bone, fibrin, slough, biofilm, and/or devitalized tissue.
- Document the type of tissue removed from the wound—not what tissue you see. For example, you may see bone in the wound. However, if you only remove muscle, you may only code debridement of muscle. In addition, if muscle was previously debrided and a second debridement is performed and only exudate and biofilm are removed, code 97597, not debridement of muscle.
- Describe what instruments and any anesthetics used.
- Document what intervals the wound will be debrided—daily, weekly etc.
- Are aftercare and any next appointment documented?
- Is the result of any previous debridement documented?
Conclusion
These are not the only guidelines on compliant practices for debridement. There are numerous valuable references and guidelines regarding debridement. Being aware of your Medicare Local Coverage Determination for wounds is very important. Be sure to print or bookmark it, have a copy handy as a reference, and compare to the templates of your electronic health record to ensure that all the required elements are present there and in any other documentation forms used in your practice.
Many audit organizations also review for these same criteria. Periodic review of your documentation will assist in navigation of an audit should one arise. Use the results of your internal audit as a basis for education pertaining to opportunities for improvement.
