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Changes in reporting wound débridement

By Mary LeGrand, RN, MA CCS-P, CPC

This year, CPT 2011 introduced multiple changes in the reporting of wound care services associated with fractures, as well as wound care not associated with an open fracture and/or dislocation.

The online version of this article includes a summary chart (PDF), showing the code changes, that can serve as an easy reference for accurate reporting of wound care services. Highlights and key changes in the Integumentary System Section of 2011 CPT are covered in this article. Next month’s article will review changes in the Repair (Closure) Skin Replacement Section.

Wound débridement not associated with open fracture or dislocation
The following guideline changes apply to débridement not associated with an open fracture or dislocation (codes 11042–11047):

  • CPT codes 11040–11041 have been deleted. New add-on codes (11045, 11046, and 11047) have been introduced, and codes 11042–11044 have been revised.
  • Changes in the section’s introductory language now require the documentation of depth of tissue débridement and the wound size (ie, surface area) in square centimeters (sq cm).

In reporting the wound size, CPT codes 11042–11044 refer to the first 20 sq cm, and the associated add-on codes (11045–11047) should be reported with the primary code for each additional 20 sq cm or part thereof. For example, if a wound requiring débridement of skin and subcutaneous tissue has a surface area of 25 sq cm, the surgeon reports 11042 for the first 20 sq cm and 11045 for the additional 5 sq cm.

The critical language in the add-on code description is “or part thereof.” Whether the wound requires 21 sq cm or 39 sq cm of surface débridement, codes 11042 and 11045 should be reported.

Modifier 51 (multiple procedures) should not be used with the add-on code for a single wound with more than 20 sq cm of surface area. Modifier 59 should be used with both the primary and add-on codes if multiple wounds of differing tissue depth require débridement to indicate the work was performed at different anatomic locations. The depth and size (in sq cm) of each wound must be reported.

The size of the débridement is based on the surface area débrided, not necessarily the size of the wound itself. For example, a wound of 25 sq cm débrided down the center to the bone (surface area 16 sq cm) would be reported using 11044 (first 20 sq cm)—not 11044 and 11047 (25 sq cm, total size of wound). Codes 11044 and 11047 would be used only if the entire surface area of the wound had débridement to the bone.

For example, a foot and ankle surgeon sees an elderly female patient with an open ulcerated area on the left lower leg and a separate lesion on the right lower leg. The surgeon documents an excision of skin, subcutaneous tissue, and muscle (4.0 cm × 3.0 cm, or 12 sq cm) in the right lower leg and an excision of skin and subcutaneous tissue in the left lower leg (3.0 cm × 8.0 cm, or 24 sq cm).

The following considerations should be taken into account:

  • Document the anatomic location, the depth of débridement, and the surface area of the wound(s).
  • Report each wound separately because the depths of débridement are different.
  • Use modifier 59 with both the distinct second procedure and the associated add-on code.

This example would be reported as shown in Figure 1, using the following codes:

11043—Débridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less (Right lower leg)

11042-59—Débridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less (Left lower leg)

11045-59—Each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) (Left lower leg)

Excisional débridement with open fracture
Descriptors were also changed for excisional débridement associated with an open fracture or dislocation (CPT codes 11010–11012). These codes describe the work associated with excisional débridement of traumatized, ischemic, hard and soft tissue and of foreign material.

Excisional débridement of an open fracture and/or open dislocation can be done to three depths: the skin/subcutaneous tissue (code 11010); the skin/subcutaneous tissue and fascia/muscle (code 11011); and the skin/subcutaneous tissue, fascia/muscle, and bone (code 11012). Each of these requires the excision or removal of tissue from the deepest layer described. In general, 11012 should be reported for a bone defect of variable size.

The parenthetical(s) was removed to address débridement of a single fracture site. Additional débridement of open wounds associated with separate stand-alone fractures (separate bones) are separately reportable. If an excisional débridement of skin alone is performed, the active wound management codes (97597–97598) should be used.

(Note: Wounds that are close together and from the same open fracture injury are reported with one débridement. In an open fracture of the radius and ulna with two noncontiguous wounds (1 cm each) where the proximal shaft of each bone perforated the skin, report code 11012 once for an excisional débridement of skin, fascia, muscle, and bone. Do not report 11012 for each wound.)

In a patient with type 3 open fractures of both the right femoral shaft and the right tibial shaft, the surgeon performs open reduction/internal fixation of both the femoral and tibial shaft fractures, using separate intramedullary implants. Figure 2 shows how this case would be submitted, using the following CPT codes:

27506—Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws

27759-51—Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage

11012-51—Débridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional débridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone

11012-59—Débridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional débridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone

The use of modifier 51 is correct because there are no bundling issues between the fractures and the first débridement. Modifier 59 (distinct procedures) is required to indicate the second débridement at a separate surgical site.

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc.This article has been reviewed and approved by members of the AAOS Coding, Coverage, and Reimbursement Committee.

AAOS Now
June 2011 Issue
http://www.aaos.org/news/aaosnow/jun11/managing2.asp