Bilateral Ulcer Debridement

“I have a patient that has bilateral ulcers with same depth on both feet, and I billed CPT 11042 -RT and CPT 11042 -LT, -59. Insurance has denied the second procedure as a duplicate. How else does this need to be billed as far bilateral ulcer procedures?”

As of January 1, 2011, the rules changed for the debridement of ulcers:
1. YOU ARE NOT REIMBURSED PER WOUND/ULCER/LESION
2. The key phrase is now 20 SQUARE CENTIMETERS
3. This is PER DEPTH OF DEBRIDEMENT of necrotic tissue from the ulcer(s) that have the same depth of debridement per body, up to and including the first 20 sq cm, not per foot, not per toe, etc.
4. Anatomical modifiers are no longer used
5. To demonstrate that different depths of debridement were used, the 59 modifier or XS modifier is used

In the example posted above, two ulcers had what appears to be necrotic, subcutaneous tissue excisionally debrided from within. One ulcer was on the right foot and one ulcer was on the left foot. Based upon the rules that went into effect on January 1, 2011, there are a few issues here:

1. Since both ulcers had the same type of necrotic tissue excisionally debrided out from within and the assumption is that the total wound surface area that was debrided was less than 20 sq cm, CPT code 11042 only needed to be billed one time.
2. Anatomical modifiers are no longer used. In fact, I am surprised that CPT 11042 – RT and CPT 11042 – LT, 59 weren’t both denied.
3. Since CPT code 11042 only needed to be billed one time on 1 line at 1 unit, billing CPT code 11042 on the 2nd line with the 59 modifier appended was moot

Therefore, the correct billing/coding scenario for the above example is quite simple: CPT 11042.

This is my opinion.

Michael G. Warshaw

DPM, CPC