Driven by an aging population and an increase in chronic conditions like diabetic foot and pressure ulcers, along with a growing trend from acute to post-acute care, the U.S. wound care market is projected to grow from more than $6.5 billion in 2023 to $10 billion by 2030. Pressure injuries alone impact approximately 2.5 million people in the U.S. each year, claiming more than 60,000 lives and adding costs to the system of anywhere from $9.1 billion to $11.6 billion.
This rapid market growth has collided with heightened complexity and advances in treatment options and devices to make debridement coding a high-risk area that can significantly impact reimbursement if done incorrectly.
A Debridement Primer
Debridement is the removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. It is done using a wide range of devices, including maggots, lasers, ultrasound, monofilament pads, forceps, scissors, scalpels or other sharp instruments capable of selectively removing nonviable necrotic tissue from a wound. Types of debridement are equally varied and include:
- Autolytic – The most conservative type of debridement, autolytic debridement is a highly selective, natural process that affects only necrotic tissue, which is softened, broken down and dissolved by endogenous proteolytic enzymes so it can be digested by a type of white blood cell called macrophages.
- Biological – Particularly effective and appropriate for large wounds, biological debridement (also called larval therapy) uses proteolytic enzymes from the sterile larvae of the Lucilia sericata species of the green bottle fly to dissolve necrotic tissue from the wound bed.
- Enzymatic – A slow, selective method, enzymatic debridement uses collagenase, an exogenous proteolytic enzyme, to debride Clostridium bacteria by digesting the collagen in the necrotic tissue allowing it to detach.
- Surgical – Done in various in- and outpatient settings, surgical debridement removes devitalized tissue in the presence of underlying infection with sharp instruments such as a scalpel, Metzenbaum, and/or curettes.
- Mechanical – A non-selective debridement that removes both devitalized tissue and debris and viable tissue, mechanical debridement is typically done with mechanical force such as wet-to-dry, pulsatile lavage, or wound irrigation.
The type of debridement, instrument used, and depth of tissue are critical for determining the appropriate CPT codes. The Centers for Medicare and Medicaid Services (CMS) provides the following guidelines:
- CPT codes 11000 and 11001 describe removal of extensive eczematous or infected skin.
- CPT codes 11042-11047 should be used for debridement of relatively localized areas depending upon the involvement of contiguous underlying structures.
- CPT codes 97597 and 97598 are categorized as “sometimes therapy” services for use by a hospital subject to the Hospital Outpatient Prospective Payment System (OPPS) for an outpatient service and will be paid under OPPS when the service is not performed by a qualified therapist, and it is inappropriate to bill the service under a therapy plan of care.
- CPT codes 97597 and 97598 should not be used if a simple dressing change is performed without any active wound procedure as described by these codes.
- CPT codes 11000-11047 are not appropriate for washing bacterial or fungal debris from feet; incision and drainage of abscess including paronychia; avulsion of nail plates; acne surgery; destruction of warts; or burn debridement.
- CPT codes 11000 and 11001 are not appropriate for debridement of a localized amount of tissue normally associated with a circumscribed lesion, e.g., ulcers, furuncles, and localized skin infections.
Additionally, local infiltration, metacarpal/digital block or topical anesthesia are included in the reimbursement for debridement services and are not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable. Finally, the care of minor wounds such as dressing changes is incidental to other covered services.
Documentation and Medical Coding Challenges
The high level of detail required for debridement documentation—which must be descriptive enough to create a clear picture of the procedure performed—is tricky to achieve. Lack of detail and/or specificity makes it difficult for medical coders to accurately determine key elements like the type of debridement performed, device used, and/or the tissue depth. This is why documentation is the culprit behind most debridement claim denials or partial denials. Contact us for assistance with medical coding, including high-risk areas like debridement.
The unique challenges of and insights into improving debridement coding are explored in the second installment of this two-part blog series on debridement coding.
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