“I have been getting insurance denials for subsequent billing of CPT code 11042 after one has been previously performed. Regardless of what level of tissue is debrided, my biller is saying I can only bill CPT code 11042 every 60 days. The biller is telling me that if I debride any level of tissue within those 60 days, I should bill CPT code 97597 until 60 days have passed. Then after 60 days, I can bill CPT code 11042. This does not seem appropriate. Should we appeal?”
CPT code 11042 is defined as the following: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq. cm or less. What does this mean? This means that necrotic subcutaneous tissue is excisionally debrided out from within an ulcerative lesion at the base of the lesion. To make the statement that CPT code 11042 can only be billed once every 60 days, or for that matter, if any level of tissue is debrided within that 60-day period that only CPT code 97597 can be billed within the 60-day period makes absolutely no sense.
CPT code 97597 is defined as the following: Debridement (e.g., high pressure waterjet w/wo suction, sharp selective debridement with scissors, scalpel & forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudates, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq. cm or less. CPT code 97597 is appropriate for either a partial thickness or a full thickness excisional debridement of necrotic tissue. This is performed within the dermis, but not to the base of the dermis if the debridement is partial thickness and to the base of the dermis if the debridement is full thickness. Not only is CPT code 97597 used for the least invasive surgical wound debridement, but it also reimburses the least.
In general, the “gold standard” for medical coding is traditional Medicare. Since this post originated in the state of Florida, the Medicare Administrative Contractor/Carrier in Florida is First Coast Service Options. Since most, if not all, Medicare Administrative Carriers have an LCD for Wound Care, I accessed the LCD for Wound Care (37166) and the associated article for Billing and Coding Wound Care (A55818) of First Coast Service Options. After carefully reading through both policies, there was absolutely nothing printed that referenced that CPT code 11042 can only be billed once every 60 days and that if any level of debridement was performed within that 60-day period, that only CPT code 97597 should be billed. I would assume that if the LCD and associated article for Wound Care of any Medicare Administrative Carrier were accessed, the same information that was provided by First Coast Service Options would be supported.
So, what is going on? I feel that there are three possibilities.
1. The health insurance carrier in question is a Medicare Advantage plan. Regardless of what their “policy” is regarding billing for wound care, Medicare Advantage plans are supposed to follow the rules and regulations of traditional Medicare. Therefore, their take on how to properly bill for wound care is certainly appealable.
2. The health insurance carrier in question is a commercial health insurance carrier. Unfortunately, they make up their own rules and if you participate with a commercial health insurance carrier that feels that CPT code 11042 can only be billed once every 60 days, if you are a participating provider, this is the policy that needs to be followed.
3. There is more to the story. Perhaps it might be best if the provider that made the above post expounds upon the posted scenario.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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