Medical Record Documentation
1. Indicate the size, depth, grade, and appearance of the wound or ulcer. This is done on every encounter.
2. Indicate the type of tissue or material removed from the wound or ulcer. The tissue or material must be necrotic. This is the sole factor that determines the debridement code to bill. The selected debridement code is based upon the deepest level of necrotic tissue that is excisionally debrided from within the ulcer.
3. Chart the location of the wound or ulcer. This is the only time in the entire process that the location is stated.
4. Indicate any anesthesia (or lack of need) used during the debridement. This is imperative for 11043 or 11044.
5. Indicate any associated status factors that may affect treatment: ie:
compromised wound oxygenation
Length of time wound present
Localized pressure affecting wound
Proximal arterial obstruction
Venous stasis disease
Small vessel ischemia
Heart failure, anemia
Need for additional consultation
Note 1: Anticipate (per CMS)
1. Most wounds will heal within 4 or fewer debridements
2. The more extensive wounds or ulcers only require 1 debridement every 1 – 2 weeks
3. Most wounds heal within 16 weeks
4. If necrotic muscle or bone are excisionally debrided anesthesia is required or a reason why it was not needed
Therefore: Debridement services that are in excess of 4 per wound or debridement services for multiple or recurrent ulcers or wounds should be clearly documented as to Medical Necessity. The use of a secondary diagnosis to indicate any associated status factors may reduce the chance of denial or review. With ICD-10-CM this is imperative. When you access the ICD-10-CM Manual and you look up Non-pressure ulcers, L97.xxx, there are instructions to “Code First” any associated underlying condition, such as:
any associated gangrene (I96)
atherosclerosis of the lower extremities (I70.23-, I70.24-, I70.33-, I70.34-, I70.43-, I70.44-, I70.53-, I70.54-, I70.63-, I70.64-, I70.73-, I70.74-)
chronic venous hypertension (I87.31-, I87.33-)
diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622)
post-phlebitic syndrome (I87.01-, I87.03-) post-thrombotic syndrome (I87.01-, I87.03-)
varicose ulcer (I83.0Ͳ, I83.2-)
Note 2: Consider
1. Pathology report for some lesions
2. A photographic history of the lesion(s). This is the best supplemental documentation that you can have. Pre and post debridement photographs should be obtained.
3. Specify the type of debridement and the instruments used (ie. Excisional debridement using a scalpel and forceps).
4. Using modifier 59 or the appropriate "X" modifier on lesions of varying depth if they represent an independent service
This is my opinion:
Michael G. Warshaw
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