Wednesday, June 26, 2019
Reimbursement Coding Articles

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Wound Care

If your practice uses the surgical debridement codes (11042-11047) every time a physician surgically removes tissue for a wound debridement case regardless of intention, your incorrect coding shortchanges your pay and sets you up for unnecessary denials, according to coding experts.
Specifically, you should not use the 1104x series when the physician surgically is preparing the patient for a skin graft to address a traumatic or acute injury, such as degloving. For those types of injuries, take a look at codes 15002-15005, which exist specifically for this purpose.
According to the CPT manual, the 1500x codes describe the initial service related to preparing a clean and viable wound surface for placement of a graft, flap, skin replacement, skin substitute or negative pressure wound therapy. Here are the codes:
15002 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq. cm or 1% of body area of infants and children
+ 15003; each additional 100 sq. cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)
15004 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq .cm or 1% of body area of infants and children
15005; each additional 100 sq. cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)
Use 1500x series for primary intention
Note that you should use the 1500x codes only for cases where the provider plans to heal the wound by primary intention, CPT states.
What that means: Primary intention is a wound-care method used for acute injuries that closes the wound with stitches or graft, for example. In contrast, secondary intention, used for chronic wounds such as diabetic or venous ulcers, promotes healing from the inside out.
Many payers and Medicare administrative contractors have policies for the 1104x series that limit their use to chronic wound patients. Practices that report those codes for care of acute wounds can wind up with unnecessary denials, such as when your diagnosis codes aren't listed in the policy.
In addition, many payer policies require that to be paid for repeat billing of the 1104x series, you must show that the margins of a wound are shrinking. That would be a typical positive outcome of chronic wound healing but not for a graft placement.
Fees for 15002-15005 are generally higher than for the 1104x series. For example, code 15002 pays $343.44 in a non-facility setting such as a physician's office, while 11043 pays $231.46 (all fees par, not adjusted for locality).
Specify primary or secondary intention
Note that providers may elect to use negative pressure wound therapy for primary or secondary wound closure.
That's one reason it's important for your providers to fully document the circumstances of a given wound-care case, including whether it's being treated by primary or secondary intention, to help with code selection.
If a patient has a degloving injury, that is, where the skin has been torn completely off a limb (like pulling off a glove) a skin graft could be required and negative pressure wound therapy often is used as part of the treatment.
Consider the following scenario: Patient had a skin abrasion on the lateral part of the tibial/fibula and ankle measuring roughly 60 cm by 7 cm and the bone was covered with muscle and some granulation tissue, debridement [was carried out], which included skin, subcutaneous tissue and a small amount of muscle. The patient had a degloving of the subcutaneous tissue  wound vac was applied.
In the above case, the code series 15002-15003 would be appropriate to report, the AMA recently confirmed by electronic correspondence.
Other cases when the 1500x series might be warranted: crush injuries and some fasciotomies, for example, a patient with compartment syndrome that the provider had to open.
When the physician does surgical debridement on a chronic wound for healing by secondary intent, 11042-11047 are still the codes to report, the CPT manual instructs.
Alternately, if you are treating necrotizing soft tissue, CPT tells you to use the 11004-11008 code series.
Code selection in the 1500x series
Pay close attention to the code descriptors for the surgical prep codes. You'll select the appropriate code based on location first and size of the area treated second.
Codes 15002-15003 encompass the trunk, arms and legs, while 15004 and 15005 describe treatment to the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits, according to the descriptors.
CPT instructs to sum the size of the surface area(s) treated within the same anatomic groupings to select the correct code and determine whether add-on codes (15003 and 15005) are necessary. So if you are treating abrasions to the hands and face you would sum the total area of both. However, if the patient has abrasions to the forearm and hands, you would not sum the total area and would instead bill with two separate codes.
For children age nine and younger, you'll select the code(s) based on percentage of body surface area instead of square centimeters, CPT instructs.

Source: Coding Answers
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