I have a patient with diabetic peripheral neuropathy and foot ulcers. I have been debriding the ulcers every two weeks, and we have billed out CPT 11042. Cigna has denied our latest two claims and the EOB says, “Procedure code is invalid for DOS and global.” There is no global for CPT 11042 and there should not be a procedure code invalid for any DOS with these claims. Any thoughts on what to do next?
So, a patient has diabetic neuropathy and foot ulcers. The ulcers have been debrided every two weeks and the CPT code that was billed is CPT code 11042 which is specifically defined as the following: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq.
cm or less. It is important to remember that the debridement CPT code that is selected is not based upon how deep the excisional debridement is performed within the ulcer, but what was the deepest level of necrotic tissue that was excisionally debrided out from within the ulcer or ulcers on the date of service in question.
The above post states that the patient has more than one ulcer and every two weeks necrotic subcutaneous tissue was excisionally debrided out from within the ulcers. This could be the reason why the last 2 claims for CPT code 11042 were denied and the EOB stated: “Procedure code is invalid for DOS and global.”
It is correct. CPT code 11042 has a postoperative global period of “0” days. I do not believe that the issue here is a “global period” in the true sense. When it comes to the excisional debridement of necrotic tissue from within the base of an ulcer, it is expected that improvement will be documented. The goal of the debridement process is to heal the ulcer in a timely fashion. This goal needs to be documented within the medical record, at minimum on the date of the initial excisional debridement. From a Traditional Medicare standpoint, when it comes to the debridement of an ulcer, they expect to see improvement within 30 days. If there is no improvement in 30 days, the assumption is that some other treatment will be initiated, or the patient will be referred elsewhere. Cigna is certainly not going to reimburse for an extended period when CPT code 11042 is billed on each occasion.
What was not stated in the post was for how long and how many times the diabetic ulcers have been excisionally debrided, specifically using CPT code 11042. If CPT code 11042 has been billed for an extended period of time, clearly there is no specific evidence that the ulcers are improving. Even if the measurements of the ulcers, both pre-debridement and post-debridement are decreasing, the fact that CPT code 11042 is billed for the diabetic ulcers repeatedly is problematic. For improvement to be noted, at some point, the level of necrotic tissue that needs to be debrided should decrease to either full thickness or partial thickness within the dermis.
The bottom line is that the medical record must demonstrate improvement. If it does not show improvement, it will be difficult to justify the reimbursement after the point that Cigna will no longer pay.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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