Wound care comprises all components of wound management including complicated conditions. This also includes other issues such as sepsis, ulcers, nutritional issues, and other bodily changes. Wound care is also a large part of the total reimbursement income for physicians or healthcare centers/hospitals.
For the same reason, billing and coding for wound care is a challenge and requires a systematic review of the wound record, its dimensions, and other ailments such as diabetes affecting the wound, procedures, and progress.
Here Are Some Coding Rules For Apt Reimbursement:
NCD and LCD:
All billing and coding professionals must follow National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) as these provide Medicare coverage rules for wound care and ensure apt reimbursements.
Medicare coverage rules include utilization and documentation guidelines, covered diagnosis codes, coverage limitations/necessities, and covered/non-covered product codes, modifiers, and procedure codes.
If these conditions are not met, sometimes, the wound care professional provides the Medicare beneficiary an Advance Beneficiary Notice of non-coverage (ABN) for ensuring payments.
E&M:
Wound care involves care and evaluation and management (E&M). The coder must be aware that an E&M service cannot be paid along with another procedure for the same encounter.
Exceptions are possible, and due to NCCI edits, column one and two codes must be considered. Medicare G0463 codes have replaced all E&M codes (Medicare specific cases).
Modifier 25:
It must be used appropriately, and not confused between selective and non-selective debridement. Coders must also code for the deepest layer of debridement, not multiple layers. Wound dressing must be coded separately, not with the E/M service.
Addition and Deletions:
CPT codes 11040 and 11041 have been deleted and for skin debridement (dermis and epidermis), codes 97597 and 97598 must be used. Code 97597 emphasizes how wound care is separate from integumentary wound care. Further, a new T-code has been initiated in the CPT category III section.
Codes:
11042-11047: To be used for foot and vascular ulcers. Used in cases of a procedure performed. These are not to be used for “washing bacterial or fungal debris from lesions, 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.”
These codes must further not be used with 97597-97062 for the same wound. 97597 and 97598 must be used for repeated wound debridement and are sometimes also considered as therapy codes. (97062 are not paid separately under Medicare).
11042: Used for debridement, subcutaneous tissue – for the area of the first 20 sq. cms or less.
+11045: Same as above, for more than 20 sq.cms.
11043: Muscle or fascia debridement, first 20 sq. cms or less.
+11046: Used in cases the same as above, for more than 20sq. cms.
11044: Bone debridement, first 20 sq. cms or less (muscle and/or fascia too).
+11047: Same as above for more than 20 sq. cms.
All of the six above include dermis, epidermis and subcutaneous tissue. It must be noted that codes 11043, 11044, 11046 and 11047 must be billed in place of outpatient or inpatient hospital or ambulatory surgical center (ASC).
Wound debridement is reported by the distance downward (of the tissue) and by the surface area of the wound. Usually, the deepest level of the tissue that is removed must be reported. In the case of multiple wounds, the sum of the surface area of wounds which have the same depth must be reported and coded appropriately.
Coding is an essential part of reimbursement. It must be done by qualified professionals. All documentation must be complete and support the HCPCS being billed for. Apt billing and coding can ensure reimbursements for physicians up to the last cent.
FAQs:
Q. What does wound care include?
A: Wound care involves managing all aspects of wounds, including complex conditions like sepsis and ulcers, as well as related issues such as nutritional problems and diabetes.
Q. Why is billing and coding for wound care challenging?
A: It’s challenging because it requires a detailed review of wound records, including dimensions and related health issues, and adherence to specific coding rules and guidelines.
Q. What are NCDs and LCDs?
A: National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) are Medicare rules that outline coverage and reimbursement guidelines for wound care.
Q. What role does Modifier 25 play in wound care coding?
A: Modifier 25 is used to differentiate between E&M services and other procedures performed in the same encounter. It’s important for accurate billing of wound care services.
Q. How have wound care coding rules changed recently?
A: CPT codes 11040 and 11041 have been deleted and replaced with codes 97597 and 97598 for wound debridement. New codes and guidelines now apply to specific wound care procedures.
