CPT code and Description
11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle, and/or fascia, if performed); first 20 sq cm or less
11047 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle, and/or fascia, if performed); each additional 20 sq cm, or part thereof
(List separately in addition to primary procedure)
Coding Guidelines
- Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 – 11047. Wound debridements (11042-11047) are reported by depth of tissue that is removed and by surface area of the wound. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. See CPT coding guidance for proper use of the coding.
- Do not report 11042 -11047 in conjunction with 97597-97602 for the same wound.
- CPT code 11043, 11046 and 11044, 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC).
- CPT codes 11043, 11046 and 11044, 11047 are codes that describe deep debridement of the muscle and bone.
Reasons for Denial
- Performing deep debridement in POS other than inpatient hospital, outpatient hospital or ASC
- Billing of debridement by unqualified personal.
INVOLVING SUBCUTANEOUS TISSUE AND DEEPER
• 11044 Debridement, bone , incl subcutaneous tissue, muscle, and/or fascia, epidermis and dermis, first 20 sq cm or less
• 11047 each additional 20 sq cm
• The above 2 can be billed together with no modifier as it is an add on code
Debridement’s
• These codes maybe subject to LCD’s:
• 11042 Skin, Subcutaneous Tissue
• 11043 Skin, Subq , Muscle
• 11044 Skin, Subq , Muscle, Bone
• These codes are reported by size (in sq cm) and there are add-on codes in addition to the codes above.
COMPLEX REPAIR: includes the repairs of wounds requiring more than layered closure, viz., scar revision, debridement, (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a defect for repairs (eg, excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions.
Instructions for listing services at time of wound repair:
- The repaired wound(s) should be measured and recorded in centimeters, whether curved, angular or stellate.
- When multiple wounds are repaired, add together the lengths of those in the same classification (see above) and from all anatomic sites that are grouped together into the same code descriptor. For example, add together the lengths of intermediate repairs to the trunk and extremities. Do not add lengths of repairs from different groupings of anatomic sites (eg, face and extremities). Also, do not add together lengths of different classifications (eg, intermediate and complex repairs).
- Decontamination and/or debridement: Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure. (For extensive debridement of soft tissue and/or bone, see 11044) (For extensive debridement of soft tissue and/or bone, not associated with open fracture(s) and/or dislocation(s) resulting from penetrating and/or blunt trauma, see 11044.) (For extensive debridement of subcutaneous tissue, muscle fascia, muscle, and/or bone associated with open fracture(s) and/or dislocation(s), see 11010-11012.)
- Involvement of nerves, blood vessels and tendons: Report under appropriate system (Nervous, Cardiovascular, Musculoskeletal) for repair of these structures. The repair of these associated wounds is included in the primary procedure.
Simple ligation of vessels in an open wound is considered as part of any wound closure. Simple exploration of nerves, blood vessels or tendons exposed in an open wound is also considered part of the essential treatment of the wound and is not a separate procedure unless appreciable dissection is required. If the wound requires enlargement, extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or coagulation of minor subcutaneous and/or muscular blood vessel(s), of the subcutaneous tissue, muscle, fascia, and/or muscle, not requiring thoracotomy or laparotomy, use codes 20100-20103, as appropriate.
Surgical Debridement
Medicare’s Supplementary Medical Insurance (Part B) covers physician services and outpatient care, including surgical debridement. Physicians use codes from the American Medical Association’s Current Procedural Terminology (CPT) to bill Medicare for these services. There are five CPT codes for surgical debridement which are based on the level of skin, tissue, muscle, or bone removed. These CPT codes are:
11044 – Debridement; skin, subcutaneous tissue, muscle, and bone.
Average Fee Schedule Amounts for Surgical Debridement Services Provided in Nonfacility Settings, 2004
CPT Code Amount
11044 $301.14
METHODOLOGY
We based this study on data from several sources: (1) a medical record review of a stratified simple random sample of allowed Part B surgical debridement services, (2) a review of carrier policies and other documentation, and (3) structured telephone interviews with carrier staff. A detailed description of the sample selection and medical review is provided in Appendix A.
We selected a stratified simple random sample of 400 claim line items for surgical debridement services from CMS’s National Claims History file.12 We identified all of the allowed claims with CPT codes 11040, 11041, 11042, 11043, and 11044 that had service dates in 2004 and allowed reimbursements of at least $15. At the start of our review, 2004 was the most recent full year of Medicare claims data available. The population consisted of approximately three million claims that represented about $188 million in allowed payments.
To improve our estimates of improper payments, we stratified our population based on Medicare allowed payments. The first stratum included all claims with allowed payments greater than $100. The second stratum included all claims with allowed payments less than or equal to $100 and at least $15. We looked for differences in the error rates between the two strata.
Our sample of 400 claims included a total of 402 services for review.13 We requested the medical record from the physician for each of these services. We based our review on 368 of the 402 services, corresponding to a 92-percent response rate. We did not include the other 34 services in our analysis because we were unable to locate current addresses for the physicians.
We used a contractor to conduct the medical review. The reviewers included three physicians with experience in wound care and three certified professional coders. In collaboration with the reviewers, we developed a review instrument that was based on Medicare program requirements. One physician and one coder reviewed each of the
medical records: the physician determined whether the service was medically necessary, and the coder determined the appropriate CPT code and modifier(s) for the service.
In addition, we reviewed the carriers’ LCDs that addressed surgical debridement services. We compared these LCDs to assess their similarities and differences. We also reviewed documentation provided by the carriers about the safeguards they had in place related to surgical debridement services. Lastly, we conducted structured telephone interviews with staff at each of the carriers that were responsible for overseeing coverage and payment issues. Our questions focused on any policies and safeguards they had to prevent improper payments for surgical debridement services. We conducted these interviews between December 2005 and February 2006.
Detailed Description of Sample Selection and Medical Review
Sample Selection
We selected a stratified simple random sample of 400 claim line items for surgical debridement services from CMS’s National Claims History file.25 To do this, we identified all of the allowed claims with CPT codes 11040, 11041, 11042, 11043, and 11044 that had service dates in 2004.26 We included only claims that had allowed reimbursements of at least $15 to focus our review on higher dollar claims.27 The population consisted of 3,139,435 claims that represented $188,262,601 in allowed
payments.
To improve our estimates of improper payments, we stratified the population by allowed amount. We also looked for differences in the error rates between the two strata. Table 1 below shows the two strata and the number of claims we selected from each.
DEBRIDEMENT
11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less
CPT 11044
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq. cm. or less.
This code is used to report the first 20 sq. cm. of bone. Any tissue superficial to the bone would be included and not separately billable. There is a 0 day global and the relative value unit is 8.93.
CPT 11047
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq. cm. or part thereof (list separately in addition to code for primary procedure).
This code is to be used when more than 20 sq. cm. of bone are debrided. For each additional 20 sq. cm. (or part thereof), you would code 11047. There is a 0 day global and the relative value unit is 3.53.
(CPT 11044/11047 coding example: If you debrided a 47 sq. cm. wound to bone, you would code: 11044 x 1 for the first 20 sq. cm., plus 11047 x 2 for sq. cm. 21-40 and sq. cm. 41-47. The total RVU would be 8.93 + 3.53 + 3.53 = 15.99.)
Multiple Levels of Debridement Coding Example:
The patient has five wounds. There is a superficial blister on the right 1st MTPJ, an ulceration that penetrates to subcutaneous tissue beneath the left second metatarsal head, an ulceration that penetrates to subcutaneous tissue on the right anterior leg, an ulceration with necrotic Achilles tendon exposed on the posterior right heel, and a lateral left fibular malleolus with bone exposed.
1) Debrided 2 x 3cm Right 1st MTPJ skin ulcer = 97597
2) Debrided 2 x 1cm subcutaneous ulceration plantar 2nd metatarsal head as well as the subcutaneous 5 x 4 right leg ulceration = total 22 sq cm = 11042 for the first 20 sq. cm. plus 11045 for additional 2sq. cm.
3) Debrided 7 x 4cm necrotic Achilles tendon ulceration = 11043 for the first 20 sq. cm. and 11046 for additional 8 sq. cm.
4) Debrided 0.5 x 0.5cm necrotic bone on the left lateral malleolus = 11044
Predictors of wound complications following major amputation for critical limb ischemia In 2011, several coding changes occurred in the area of wound management. The commonly used CPT codes 11040 and 11041 were deleted, and replacing them for skin debridement are the active wound care management CPT codes 97597 and 97598. The second major change is the need to measure and report based on the surface area of wound(s) debrided. The first 20 square centimeters of area treated will be reported with a primary code, and any area beyond that will be billed using add-on CPT codes in 20 square centimeter increments or part thereof. As in the past, the debridements will still be reported based on depth of tissue removed. The first level involves only skin (either partial or full thickness), the second encompasses skin and subcutaneous tissue, the third comprises skin, subcutaneous tissue, and muscle and/or fascia, and the deepest level contains skin, subcutaneous tissue, muscle and/or fascia, and bone. The third major change is that all of the primary CPT debridement codes (97597, 11042, 11043, and 11044) now have a 0-day global period. Previously, CPT codes 11043 and 11044 were assigned a 10-day global period by the Centers for Medicare and Medicaid Services.
Debridement services may be reported for injuries, infections, wounds, and chronic ulcers. When performing debridement of a single wound, choose a CPT description that corresponds to the deepest level of tissue removed. In multiple wounds, calculate the surface area for all wounds which are at that same depth (regardless of location in the body), but do not combine sums from different depths. The new add-on codes 11045, 11046, and 11047 are used to report debridement of each additional 20 square centimeters at the three different depths: subcutaneous tissue, muscle/fascia, and bone, respectively. These three add-on codes can be reported multiple times as appropriate, but may be subject to frequency edits by the insurance carrier. The add-on CPT code descriptors all include the phrase “or part thereof,” which means that one does not need to debride an entire additional 20 square centimeters to submit the add-on code. For example, if 30 square centimeters of skin is debrided, report the primary CPT code (97597) plus the add-on CPT code (97598) for that level of depth. Last, removing a collar of callus (hyperkeratotic tissue) around an ulcer is not considered a true debridement.
Documentation is required to justify the indication, the treatment plan, and the procedure itself. Private carriers have their own guidelines ,while regional Medicare carriers produce Local Coverage Determinations (LCDs). The regional Medicare carrier Trailblazer has LCD 4S-150AB-R9 (L26721) which requires the medical record contain clearly documented evidence of the progress of the wound’s response to treatment at each physician visit, while the procedure notes must characterize the tissue removed and the method of excision. The local Medicare carrier NGS LCD L27373 (R9) has medical necessity edits that deny reimbursement for the debridement CPT codes detailed above when paired with the “cellulitis and abscess” diagnoses (ICD-9 codes 682.X) and other diagnoses that lack ulcer or wound in their description. All vascular providers should consult their regional Medicare carrier websites for active LCDs that govern debridement services in their area of practice.
Wound Care – CPT Codes
• Surgical Debridement Codes:
- 11040 Debridement skin, partial thickness
- 11041 Debridement skin, full thickness
- 11042 Debridement skin/tissue
- 11043 Debridement tissue/muscle
- 11044 Debridement tissue/muscle/bone
- Documentation must clearly represent these procedures
• Instruments used, and depth of debridement - These codes are “designed” to reflect physician services.
- Review PM A-02-129 – January 2003
- UGS (FI) states this should not be performed by Physical Therapists. Be sure to check with your FI
CPT 11043 Debridement; Skin, subcutaneous tissue, and muscle
Procedure description: The physician surgically removes necrotic skin, underlying tissue, and muscle. The physician uses a scalpel, curette or dermatome to remove/excise the affected tissue into the muscle. The dissection is continue until until viable, bleeding tissue is encountered. Depending on the size
the closure may be immediate or delayed. The wound may be packed open with sterile gauze and may require delayed reconstruction.
Report CPT 11044 is Debridement same as above but when the bone is also debrided.
Surgical debridement (Excisional) Billing and documentation requirements:
- The debridement code submitted should be based on the type and amount and the surface area of tissue removed, not based on the depth, size, or other characteristics of the wound. Document should support coded anatomical site, area of body surface debrided and or extent of tissue or foreign material debrided (e.g. if a
wound involves exposed bone but the debridement procedure did not remove bone, CPT code 11044 cannot be billed). - When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths.
- For debridement of skin, i.e., epidermis and/or dermis only, see 97597, 97598.
- Dressings applied to the wound are part of the service for CPT codes 11000-11001 and 11042- 11047 and they may not be billed/ reimbursed separately.
- The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from feet, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Report these procedures, when they represent covered, reasonable and necessary services, using the CPT code that most closely describes the service supplied.
- E/M codes are not usually billed in conjunction with a surgical debridement code. Surgical debridement code includes the pre-debridement wound assessment, the debridement, and the post-procedure instructions provided to the patient on the date of the service. Only significantly separately identifiable service are
performed and reasonable as well as distinct, from the debridement service(s) provided a separate E/M can be claimed. - Codes 11040-11044 are considered complex surgical services performed by physicians.
In Coding Guidelines: In sentence Number 3, removed 11043 and 11046 to read: “CPT codes 11044 and 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC).” In sentence Number 4, added “/or” to read: “CPT codes 11043, 11046 and 11044, 11047 are codes that describe deep debridement of the muscle and/or bone.”
In Reasons of Denial: Sentence Number 1, removed the word “deep” and added “bony” to read: “Performing bony debridement in POS other than inpatient hospital, outpatient hospital or ASC.”
CPT Procedure Code 11044 – DMA Global Days Update
The Centers for Medicare & Medicaid Services (CMS) changed the global period on procedure code 11044 [debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed), first 20 sq cm or less] to “0” global days effective with dates of service January 1, 2011. The N.C. Division of Medical Assistance (DMA) had the code set to 10 global days (the global period prior to January 1, 2011), but the global period has been corrected to “0” global days as required by CMS.
Providers with claims for codes that denied due to the post-op days on this code should void the claim that was denied, as well as the claim containing code 11044. A new claim for both should be submitted. If the claim for code 11044 cannot be identified, the provider should submit an adjustment request for the denied claim, noting the denial is related to changes in global days for 11044.
Physician Procedures
There are many procedures performed by Physicians on wound care patients in the hospital outpatient setting. The Physician bills procedures on a 1500 claim form with a site of service indicator “hospital outpatient”, the hospital bills on a UB04 claim form for the “technical” component of the procedure.
11044 – Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less.
