“I was working at the local wound care clinic last week when this scenario presented itself. The patient was referred from the emergency room for follow for a wound. His wound was a deep wound at the medial malleolus of the right ankle. The posterior tibial tendon was right there, as clear as day. There was necrotic and fibrotic tissue around the tendon. I debrided the area, including the tendon, and all surrounding non-viable tissue. The patient had a superficial wound at the right hallux. Here are my questions:
1. Can we bill CPT 11043 and CPT 11044 in a wound care center?
2. Are we allowed to bill more than one wound debridement during the same visit?
3. Can I bill an E/M for the hallux wound, if only debrided the ankle wound?”
A patient was referred to the wound care clinic from the emergency room with a deep wound/ulcer overlying the medial malleolus on the right ankle. The posterior tibial tendon was clearly visible, and it was affected by necrotic and fibrotic tissue. Both the surrounding area and the posterior tibial tendon were debrided of non-viable tissue. With the assumption being that this was the deepest level of necrotic tissue within the base of the wound/ulcer, the most appropriate CPT code to bill would be CPT 11043 which is defined as the following: Debridement, muscle and or fascia (includes epidermis and dermis, and subcutaneous tissue if performed); first 20 sq. cm or less).
Not all Medicare Administrative Contractors expect CPT 11043 or CPT 11044 to be performed in an office setting. In the posted scenario, CPT 11043 was performed in the wound care clinic. With very few exceptions, wound care clinics are considered to be part of the hospital. However, to play it safe, I would confirm with the Medicare Administrative Contractor in question that it is reimbursable to perform CPT 11043 in the wound care clinic. This addresses Question #1.
The other issue that was present was a superficial wound on the right great toe. Unfortunately, there is not a description of the wound with respect to the depth and the presence of necrotic tissue within the wound. If there was necrotic tissue either partial or full thickness that needed to be excisionally debrided out from within this wound, CPT 97597 would be the appropriate CPT code to bill. It 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. With the assumption being that both wounds/ulcers that were present, the one overlying the right medial malleolus and the one on the right great toe needed to be excisionally debrided of necrotic tissue within the base of the respective lesions, it would be appropriate to bill both CPT codes. The coding scenario would be the following:
CPT 11043
CPT 97597 – 59
This addresses Question #2.
If the only debridement that was performed addressed the wound/ulcer overlying the right medial malleolus, clearly CPT 11043 is the correct CPT code to bill. The issue now is that if the ulcer/wound on the right great toe is not debrided, can an E/M service be billed? The documentation in the medical record absolutely must demonstrate that treatment was rendered to the ulcer/wound on the right great toe.
Remember how an E/M service is defined:
1. E/M is NOT a synonym for an office visit. It is a 2 part process:
2. a.” E” stands for EVALUATION. Using a Medically Appropriate History and/or Examination and *Medical Decision Making, you formulate a WORKING DIAGNOSIS.
This shows MEDICAL NECESSITY.
b. “M” stands for management. Using the working diagnosis, you now have to do something about it. In other words, you have to TREAT THE PROBLEM. Diagnosing a problem is not sufficient.
3. *Total Time can be used in lieu of Medical Decision Making in order to determine the most appropriate level of E/M service as long as the total time is appropriately documented within the medical record for the date of service in question.
Based upon the appropriate documentation that demonstrates how specifically the ulcer/wound on the right great toe was treated medically as opposed to procedurally, the appropriate level of E/M service can be billed. Of course, the E/M service would need to be appended by the 25 modifier. The 25 Modifier is used to demonstrate that a SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M service was performed on the SAME day of a MINOR surgical procedure by the SAME physician. This addresses Question #3.
This is my opinion.
Michael G. Warshaw, DPM, CPC
GREAT NEWS!!!
THE 2024 PODIATRY CODING MANUAL IS NOW AVAILABLE in either Book or Flashdrive formats. It has been completely updated for the calendar year 2024. Many offices across the country consider this to be their “Bible” when it comes to coding, billing, and documentation. The price is still only $125 including shipping! To purchase, access the website drmikethecoder.com.
No credit card? No problem! Just send a check for $125 to the following address:
Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, Florida 32757
Read Comments