Reporting of Wound Debridement Procedures Properly

There are lessons to be learned to avoid damaging coding habits.

Wound debridement is a medical procedure that removes infected, damaged, or dead tissue to promote healing. Debridement is generally associated with injuries, infections, wounds, and/or ulcers. It is also a procedure that may be part of fracture care as well, and it is separately payable. To better understand how to code for wound debridement properly, let’s first look at why debridement is performed, and how it’s accomplished.

Wound Debridement
CPT® codes 11042-11047 describe the work performed during wound excisional debridement. An excisional debridement can be performed at a patient’s bedside or in the emergency room, operating room (OR), or physician’s office. Some key elements to look for in the documentation are the following:

• The technique used (e.g., scrubbing, brushing, washing, trimming, or excisional)
• The instruments used (e.g., scissors, scalpel, curette, brushes, pulse lavage, etc.)
• The nature of the tissue removed (slough, necrosis, devitalized tissue, non-viable tissue, etc.)
• The appearance and size of the wound (e.g., fresh bleeding tissue, viable tissue, etc.)
• The depth of the debridement (e.g., skin, fascia, subcutaneous tissue, soft tissue, muscle, bone)
• To determine the proper code choice, first, consider the depth of the debridement. This is determined by the deepest depth of removed tissue. Keep in mind that the wound may extend to the bone, but if only subcutaneous tissue is removed, the depth of debridement is to the subcutaneous tissue only.

Subcutaneous Tissue 
11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

+11045 each additional 20 sq cm, or part thereof (list separately, in addition to the code for primary procedure)

Muscle or Fascia  
11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

+11046 each additional 20 sq cm, or part thereof (list separately, in addition to code for primary procedure)

Bone
11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

+11047 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

When debridement is performed to the same depth on more than one wound, the surface area of the wounds is combined. When the depth is different for two or more wounds, each wound is coded separately.

The second aspect of picking the proper wound debridement code is determining the surface area of the wound. If the entire wound surface has been debrided, the surface area is determined by the square centimeters of the wound after the debridement has been completed. If only a portion of the wound is debrided, report only the measurement of the area actually debrided.

Wound Care Management/ Wound Surface Biofilm, Epidermis, Dermis 
The CPT® codebook directs us to use the active wound care management codes 97597-97598 for debridement of the skin (i.e., epidermis and dermis only):

97597 Debridement (for example, high-pressure water jet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), open wound, (for example, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq. cm or less

+97598 each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure)

Notice that the description states “selective debridement” versus “non-selective,” as captured by:

97602 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (for example, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session.

Selective debridement is the removal of non-viable tissue, with no increase to wound size, and typically, no bleeding, because the tissue removed is non-viable. Non-selective wound debridement is usually done by brushing, irrigation, scrubbing, or washing of devitalized tissue, necrosis, or slough. In non-selective wound debridement, the focus goes beyond the non-viable tissue.

Example No. 1: The patient has a pressure ulcer. The physician examines the ulcer and uses a pressure water jet to debride the skin and eschar from the wound; approximately 15 sq cm of surface area was selectively debrided. The wound is left open to continue healing. This is an example of selective wound care, CPT code 97597.

Fracture Debridement
Fracture and dislocation debridement codes 11010-11012 are based on the depth of the tissue removed, and whether any foreign material was removed at the same time.

11010 Debridement, including removal of foreign material at the site of an open fracture and/or an open dislocation (excisional debridement); skin and subcutaneous tissues

11011 skin, subcutaneous tissue, muscle fascia, and muscle

11012 skin, subcutaneous tissue, muscle fascia, muscle, and bone

Repeat debridement may be necessary in certain circumstances. When coding for a “staged” or “planned” debridement during the usual postoperative follow-up period of the original procedure, it’s important to use the appropriate modifiers. Use Modifier 58, Staged or related procedure or service by the same physician or qualified health care professional during the postoperative period, in the following instances:

• When the debridement procedure(s) are staged prospectively at the time of the original procedure, or during the usual postoperative follow-up period of the fracture treatment.
• When the staged procedure is more extensive than the original procedure: for example, when an initial debridement procedure(s) is performed and a larger procedure (e.g., definitive open fracture treatment) is a staged surgical intervention.
• When other reconstructive procedure(s) (skin graft, myocutaneous flap, vessel graft, etc.) are planned or staged prospectively at the time of either the original procedure or during the usual postoperative follow-up period of other reparative procedure(s) and/or fracture treatment.
• When the initial fracture care includes “excisional debridement” at the site of an open fracture, a 59 modifier or an -XU modifier may be necessary to report to the payer, noting that this was a “distinct procedural service” and/or a non-overlapping service to the original procedure.

Example: The patient was in an automobile accident and sustained an open fracture of the left femur. On the day of the accident, the patient was brought to the OR, and the open fracture was debrided of all necrotic tissue and debris. Under fluoroscopic guidance, the surgeon was able to manipulate the bone to create an ample reduction. An external fixator device was used, and a dressing was applied to the open area. The open fracture of the femur is 27269, and the debridement would be 11010, along with a -59 modifier to bypass any edit, as referenced in CPT® Assistant.

Two days later, the patient was returned to OR and the dressing was removed. The surgeon examined the open fracture and irrigated the wound with saline. An area of 3 cm x 4 cm was dark. The subcutaneous tissue and skin was excised with a No. 15 blade to bleeding tissue. Some nonviable muscle tissue was also debrided. The area was then copiously irrigated, and a dressing was placed.

Coding for the second debridement is 11011-58.