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May 9, 2012

Documenting Surgical Debridement Services - Measurements Matter

The correct coding of surgical debridement services (CPT 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.

One common error is reporting CPT 11043 when muscle and tendon are visible, but NOT actually surgically debrided. The potential exists for similar errors to occur when bone is visible, but not documented as being part of the surgical debridement procedure. It would not be appropriate to code CPT 11043 and 11044, respectively in these instances when they involve the same wound site. It is the deepest level of tissue removed from a uniquely identifiable wound that determines the correct code.

Documentation supporting the correct use of the surgical debridement "add-on" codes 11045 – 11047 communicating that > 20 square centimeters (cms2) of tissue were surgically debrided should reflect the actual area of devitalized tissue removed and not routinely set as being equal to the total area of the wounds in question. This latter point is particularly important in Electronic Health Records (EHRs) that are capable of automating the completion of key data elements based on certain pre-populated fields. For the purposes of CPT code selection and units, the wound measurements used are the amount debrided, not the total wound size, before or after debridement. Selecting CPT codes and units based on total wound size may result in incorrect coding and reimbursement.

By accurately documenting the size of the devitalized tissue, before and after the surgical debridement, and adhering to the coding and billing rules for surgical debridement services, you help ensure that claims payment errors are prevented and that the J15 AB MAC claims payment process is kept as efficient as possible.

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