GSURG-037 Application of Bioengineered Skin Substitutes and Skin Grafting
WPS has received multiple inquires regarding updates made to the local coverage decision GSURG-037 Application of Bioengineered Skin Substitutes and Skin Grafting *(Wound Care).
- Does this new Local Coverage Decision (LCD) apply to wound care that provides removal of necrotic tissue for patients who are not candidates for a skin substitute or graft?
Yes, LCD GSURG-037 now includes all wound care. Since wound care is closely related to skin substitutes and/or grafting, this information was added to LCD GSURG-037. - LCD GSURG-037 has different information in the actual policy and the Billing and Coding Guidelines regarding covered place of service for Current Procedural Terminology (CPT) codes 11043 and 11044. Which is correct?
11043 Debridement; skin, subcutaneous tissue, and muscle
11044 Debridement; skin, subcutaneous tissue, muscle, and bone
Both the LCD and Billing and coding guidelines have been updated to reflect that CPT codes 11043 and 11044 may be rendered in places of services inpatient hospital, outpatient hospital and ambulatory care centers (ASC). If the service is rendered in another place of service, please request an appeal with a copy of the operative report and plan of care. - Why is WPS denying CPT code 11043 when the chronic nature of these wounds is that debilitated elderly patient frequently requires multiple debridements of necrotic tissue and slough, which is beneficial to wound healing, and prevents morbidity and mortality from wound progression and generalized sepsis?
WPS agrees that the chronic nature of these wounds in the debilitated elderly patient frequently requires multiple debridements of necrotic tissue and slough, which is beneficial to wound healing, and prevents morbidity and mortality from wound progression and generalized sepsis. However, the correct coding to bill for these services with rare exception is CPT code 97597 or 97598.
97597 Removal of devitalized tissue from wound(s), selective debridement without anesthesia (eg, high pressure water jet with/without suction, sharp debridement with scissors, scalpel and forceps), with/without use of whirlpool, topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 20 square centimeters.
97598 Removal of devitalized tissue from wound(s), selective debridement without anesthesia (eg, high pressure water jet with/without suction, sharp debridement with scissors, scalpel and forceps), with/without use of whirlpool, topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 20 sq. cm.
CPT codes 11043 and 11044 are codes that describe deep debridement of the muscle and bone. Once the initial debridement of muscle and or bone has been performed, there typically is no true necrotic muscle or bone there to be subsequently debrided. Thus, the CPT codes 97597 and 97598 are what typically are performed for subsequent debridement services. Similarly, it is expected that with any debridement, especially in a long-term facility, that daily wound care would be performed by the nursing staff. - The majority of the ulcers I treat are either Stage III or Stage IV wounds. I have to bill these services using CPT codes 11043 or 11044
The issue in this LCD is not the stage of the wound; it is what procedure is actually being performed. A Stage III wound is not automatically billed with CPT code 11043 nor is a Stage IV wound automatically billed with a CPT code 11044. - The AMA CPT Assistant states that CPT codes 97597 or 97598 are non-physician codes and physicians should use CPT codes 11040-11044 when billing debridement of a wound.
Medicare does not acknowledge CPT Assistant as a coding authority. CPT Assistant (June 2005/Volume 15, Issue 6, states, "These codes are to be reported by non-physician professional" and "For wound debridement performed by physicians, see codes 10040-11044." CPT Assistant instruction assumes that the service performed by the physician is wound debridement.
However, on page xiv of CPT 2007(professional edition), it states:
"It is important to recognize that the listing of a service or procedure and its code number in a specific section of this book does not restrict its use to a specific specialty group. Any procedure or service in any section of this book may be used to designate the service rendered by any qualified physician or other qualified health care professional."
Similarly, on page 416, there is no mention of any restrictions on this code to any specialty.
Medicare Part B covers medically necessary wound debridements performed by non-physician practitioners. It is WPS' interpretation of this instruction that the AMA wants CPT codes 97597-97606 to be used by all providers who are performing Active Wound Care.
Most likely, when a beneficiary requires repeated debridement, CPT 97597 or 97598 is the service performed, although at times CPT 11040-11042 may also be the true service.
Page Last Updated: Thursday, 18-Mar-2010 05:55:29 CDT
