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Unidentified Male Speaker: I'm going to be introducing you our next speaker. His name is Dr. Jeffrey Lehrman and he is in private practice just outside of Philadelphia, and he's a Heat fan. Not really a Heat fan? No? I'm a Heat fan. He must be a '6ers fan. He's a Diplomate of the American Board of Foot and Ankle Surgery, Fellow of the American Society of Podiatric Surgeons, and is recognized as a "Master" by the American Professional Wound Care Association. He is a Fellow of the American Academy of Podiatric Practice Management, serves on the APMA Coding Committee and APMA MACRA Task Force, and is an Expert Panelist on Codingline.

He sits on the Board of Directors of both the American Professional Wound Care Association and the American Society of Podiatric Surgery. Dr. Lehrman is an adjunct professor at Temple University School of Podiatric Medicine and trains residents and medical students at his hospital system. He is also an Editorial Advisor of the journal of WOUNDS and is a Consulting Editor for Podiatry Management magazine. Welcome.

Jeffrey Lehrman: Thank you.

Unidentified Male Speaker: All right.

Jeffrey Lehrman: And it's a '6ers. I didn't catch what you said the first time. Good morning. One of the most common reason I see our colleagues fail payer audits is for incorrect coding and/or documentation of ulcer debridement. My goal is that 30 minutes from now, you have all the information you need to ensure that you are never one of those people. And you know exactly how to choose the code or codes pertinent to the wound debridement that you have performed, with no ambiguity and no guessing, and knowing exactly what you should be coding and documenting to support that code.

[02:06]

Before we get into the codes that you should be using, we're going to touch on three that you should never be using. I hope that everybody in this room knows that these two codes no longer exist. They were deleted from CPT a long time ago but I am going to continue to leave this slide in here as long as I keep getting asked about it, and seeing failed payment, and people asking, "Why am I not getting paid for these?" They're gone. This was not a specific payer or one part of the country. They were deleted from the CPT. They don't exist. If you are guilty of having a 2009 CPT book lying on your desk, and I know there are people in the room that fall into that category, cross them out because they don't exist anymore. Get rid of them. These codes are gone. Don't ever use them.

This is a code that the provider, that the doctor, should never be submitting. This is for facilities only, just making this point because I see docs use it, and then ask, "Why didn't I get paid?" It's because you shouldn't be using it. This is in the rare scenario where you are at a facility, the doctor does not perform a sharp debridement, and orders some form of non-selective debridement, and then the facility can use this code. So this is for facilities only. Don't use it.

Now, we get to the codes that we can and should be using. The code that you select, and this is the most common thing that people mess up in choosing the code and documenting to support the code. The code that you select is not based on the depth of the ulcer. The code that you select is based on the deepest depth of tissue that is removed, which often is the same as the depth of the ulcer, but not always, right?

[04:02]

We're going to through an example where maybe there's bone exposed but you don't remove any bone. You choose the code based on the deepest depth of tissue that is removed. The deepest depth to which you debride and these are your four options that you can choose from. You have to ask yourself and document, what is the deepest depth of tissue that was removed? And that is what determines the code, not the depth of the ulcer itself. But again, the deepest depth to which you debride.

So we'll go through these four, starting with dermis. If the deepest depth of tissue you remove is dermis, this is your code, 97597. And this is up to or equal to 20 square centimeters of dermal tissue removed, regardless of the number of wounds that are debrided. It doesn't matter how many you debride.

Prior to 2011, we got to use a code for each ulcer. That is no longer the case. We now have to sum the total amount of tissue removed at that depth to determine the code. So if you removed five square centimeters of tissue from one ulcer, it is exactly the same as if you removed two square centimeters of dermis from one and three square centimeters of dermis from another. I don't think that's fair but that's the deal.

If you debride to the deepest depth, being dermis, this is your code. If you debride multiple ulcers and they're all to the same depth of dermis, this is your code, up to 20 square centimeters and equal to 20 square centimeters. So you have to document the deepest depth to which you debrided, and yes, how many square centimeters of that dermal tissue was removed?

[06:00]

So we'll go through some examples just to make sure we're cool on this. First one, we've removed a total of 16, right, four by four. We've removed a total of 16 square centimeters of dermis, 97597. That's easy. But now let's say we have two and they both get debrided to the depth of dermis, in both ulcers. The deepest depth you go is dermis and on one you remove four, two times two, and in the other you remove 16. We have to add them together because the two different ulcers were debrided to the same depth, we get 20. It's the same code. It does not matter if it's the same foot. It doesn't matter if it's the same sides of ones, of five, right foot, left foot, it doesn't matter.

If it's a plastic surgeon, it could be butt and elbow if it's debrided to the same depth. It does not matter what part of the body, same foot, different foot, laterality, it doesn't matter. If they are two separate ulcers, you add them together. And then, the last one, just to make sure we're clear on this, right? So four plus six, plus four, it would be 14. Even though it's three different ulcers, it's the same code because you removed a total of less than or equal 20 square centimeters of dermis.

So I hope you're wondering, well, what happens if we go over 20 square centimeters of dermis? There's an add-on code for each additional 20 square centimeters of dermis that is removed and that is 97598. That's an add-on code. So if you – it doesn't matter one ulcer or multiple ulcers, right? If the total amount of tissue removed is over 20 square centimeters of dermis, we need 97597 for the first 20, and in addition to that 97598 for each additional 20 square centimeters. I make that point because we've seen people that go over 20.

[08:03]

They do the 97598 only and then ask, "Why am I getting paid less for doing more?" Well, you need the root code first. You need the base code first for those first 20 square centimeters and then the number of units of the 97598 is dependent upon how many chunks of 20 square centimeters are removed. It's per additional 20 square centimeters. This is an add-on code. By definition, add-on codes do not take 59 or 51, or X modifiers. That's with any add-on code.

This room probably is very familiar with 11732, right? Additional ingrown beyond 11730, no 59, no 51 on an add-on code. So we can do an example if we remove 25 square centimeters of dermis. This one says one ulcer. It doesn't matter if it's seven ulcers. If 25 square centimeters of dermis is removed, we have 97597 for the first 20 but we need to get to 25, so then one unit of that add-on code will take us there, no 59, no 51.

We'll jump to this last one. Let's say we remove 75 square centimeters of dermis. That's a lot but just to illustrate the point and how to use the add-on code, maybe it's a big giant stasis ulcer or something, right? So 75 square centimeters. So 97597 for the first 20. That gets us to 20. We need to get to 75. So then, we have 97598, it gets us to 40, the first unit. The second unit gets us to 60. We're still not there. The third unit now puts us over to 75. So that would be the appropriate coding on two lines if you remove 75 square centimeters of dermis.

[10:00]

We're going to get to the deepest depth, but this depth, these codes fall under Medicare consolidated billing, which means you need to know if this patient is under their part A stay somewhere, and that normally means, for us, skilled nursing facility, right? They go into a skilled nursing facility that's covered as a part A stay. The facility gets a bulk payment, right? Like a DRG payment for that stay, and then there's a whole big long list of codes that if any of those things happened during that stay, it falls under the bulk payment.

These codes are listed there. The deeper layers which we're getting to are not, but these codes are listed there, which means if the patient is under a part A stay somewhere, you will not get paid if you submit 97597 or 97598, and it doesn't matter where the visit takes place. It doesn't matter whether you went to the skilled nursing facility or they got transported to you in an ambulance to your wound care center, or your office.

The place of service doesn't matter. Where the visit takes place doesn't matter. What matters is, were they under a part A stay at the time that you performed the debridement? And the question to the facility is, are they currently in their part A stay? Don't make the mistake of looking at the number of days because often it's the first hundred days, but not always, right? Sometimes they do great with their crutches and they graduate from skilled care, and go to the other side of the building to the long term care side. That might happen in less than 100 days.

The person that brings them is clueless, right? The aide has no idea. So don't ask them. This is a phone call to the facility with somebody in front of a computer, is this patient under their part A stay?

[12:03]

If they are, your 97597 and eight, if you do it, will not pay. So what do you do? Well, they are getting paid for it technically, right? They got the bulk payment. What you're supposed to do is contract with the facility that they carve out a payment from you from their bulk payment to which I say, good luck, because I don't think that's happened. But that's the podium answer to how you're supposed to handle that.

So if we go beneath dermis and we – deepest depth to which debride a subQ, now, there's another set of codes, right? Now, we can go faster because it's the same deal. For the next three depths, there's going to be one code for the first 20 square centimeters, and then an add-on for each additional 20 square centimeters at that depth and it is the same thing. If there are multiple ulcers debrided to the same depth, you add together the total amount of tissue debrided at that depth if they were debrided to the same depth.

So this is subQ. If you debride dermis and the subQ in the same ulcer, if you debride dermis on your way down to subQ, we do not get to code separately for that, right? That's included. All we get is, what is the deepest depth that was removed? Then, we jump to the next level of muscle/fascia, and yes, tendon falls under this category. That's the question we get a lot.

First 20 square centimeters, each additional 20 square centimeters. Now, I'm going to say a couple of times now, check your LCD. This is a national event. There are people from all over the country so we can't focus on just Noridian, which is for Nevada and many of the other West Coast people that are here. Different LCDs have different guidelines. Some LCDs require that if you do 11043, you send the specimen to path so that you can prove that it was muscle or fascia.

[14:10]

There's a big jump in reimbursement when you go from the subQ level to the muscle, and then bone level, a big jump. So some of the LCDs want you to prove it. For those that are Noridian, which is most of the West Coast, that actually does not have that requirement in the Noridian LCD. But be safe. Check your LCD, especially if you're not Noridian. I know there are people from non-Noridian states here. Check your LCD and see if you are required to send path if you do 11043, meaning, muscle/fascia.

If you do a half a day a week at an outpatient MOON center, some of these big national chain-ran wound centers, they just put it as a protocol across the country to cover their basis. So your wound center admin people may be telling you, if you do 43 or the next one, which is bone, you must send path to prove it.

Next level is bone and this is the final level, 11044, first 20 square centimeters, and then we have the add-on code for each additional. That is the same thing, where if there are multiple ulcers, you sum them. Again, check your LCD. Noridian out there in Nevada and California does not have that requirement but many do, that you must send path. Some LCDs, and we as podiatrists know this is silly, some LCDs won't pay 11044 if it's done in the office setting, which we know is ridiculous. We get neuropathic people. We could shay bone way easily in our office. Some don't. Noridian does not have that restriction. But again, check your LCD. Some won't pay the bone level debridement if it's in the office setting.

[16:00]

So this is all for together, sort of the algorithm of the deeper you go, the more the code changes. And one more time, if there are multiple ulcers debrided to the same depth, add together the total amount of tissue debrided at that depth. So we said that 15 times. The square centimeters is the amount of tissue removed, not the square centimeters of the ulcer. So some make the mistake of measuring the ulcer and it's four by three, and they think that that determines the code, but it doesn't. It's the amount of tissue removed that determines the code and you have to document that.

The documentation should support both the size of the ulcer and the amount of tissue removed. Those are two different things and that is a reason for a failed audit. So let's do the second one because I feel like we've hammered this point here enough. Let's say we have an ulcer. It's a plantar heel ulcer and it's big and gross, and it's down to bone. So it's six by six. The ulcer is 36 square centimeters and there's bone exposed. But maybe we say, well, it's nice, hard, intact cortical bone. They just got revascularized. Maybe they can granulate over it. I'm not going to mess with the bone. I don't want to expose that soft cancellous bone, whatever.

Whatever the reason is, you decide to debride only to the depth of subQ and we're not going to mess with the bone. So the code is determined not by the depth of the ulcer but the deepest depth of tissue that was removed, which in this case is subQ. So even though there's bone exposed, we're choosing form the subQ codes. And even though the ulcer is 36 square centimeters, we only removed 12 square centimeters of subQ for whatever reason. Maybe that was the only part that was necrotic that we thought needed to go. So we removed 12 square centimeters of subQ, so that's our code, even though the ulcer is bigger than that and even though there was bone involved.

[18:07]

We said a hundred times what to do if there's two ulcers debrided to the same depth. But then, the question often comes, what if you have two different ulcers that are debrided to different depths? Then, you get to use two different codes. So this is better. If there are multiple ulcers debrided to different depths, then you can do different codes. And the Noridian – this is a CPT rule. The Noridian LCD actually spells that out and tells you that. So if they're debrided to different depths, then you can use different codes. You could have one dermis, one subQ and one muscle, and legitimately, you have three different codes there.

So I picked a little bit more of a complex example here. Let's say we have two ulcers, one of which has four square centimeters of dermis removed. The other has 36 square centimeters of muscle removed. So they were debrided to different depths. That means we don't have to add them together. So the four square centimeters of dermis, one is easy. That's 97597, right? Less than 20 square centimeters of dermis. We don't have to add them together because they were debrided to different depths. The other one have 36 square centimeters of muscle debrided. So 11043 for the first 20 square centimeters of muscle but we went over 20, we need our add-on code. And 11046 is the add-on code that goes with 11043 if we remove more than 20 square centimeters of muscle.

The add-on code never takes a 59 or a 51. But in this case, we need a 59 modifier on the 97597 and the correct coding initiative. The CCI edits is what tells us which one takes the 59 modifier. That's a whole other discussion about the CCI edits.

[20:03]

None of these can be separately coded for when you submit for ulcer debridement. All this stuff is included. If you have a topical that lives in your drawer that you are putting on the ulcer when you're done, you don't get to code for that separately. All this stuff is included. Telling them how often to change their bandage is not a separately identifiable E&M. I mentioned this already, check your LCD. Some around the country say that you must send pathology for the muscle or bone debridement. Some won't pay muscle and/or bone if it's done in the office setting. Check your LCD.

Different LCDs have different documentation requirements. And just to be thorough, there are some younger people in the room, so forgive me for those that get this. Oftentimes, I do this and then people say, "What's an LCD?" And then, I feel silly for having not described it. So hopefully you know that Medicare is a national program but it's administered on a local level.

So there are seven Medicare Administrative Contractors in our country, MACs, M-A-C. There are seven MACs. Noridian has California, Nevada, Montana, Washington, Oregon, a bunch of other ones. That's the MAC out here. Each MAC can choose to issue Local Coverage Determinations, LCDs. So they pick a service where they think it might need clarification or a service where there's been abuse, or a service where people have a lot of questions and they issue an LCD on it. Like there's always an LCD for foot care. There is an LCD for ulcer debridement.

So when I say check your LCD, that means find out who your MAC is. Go to their website. Click on the LCDs. There's a lot of them. There's like 40 to 60 depending on the MAC, and look for ones that are pertinent to what we do.

[22:04]

There'll be a bunch of staff in there that we don't care about, about eyes and cardiac things. But there are also debridement LCDs. There's skin sub LCDs. There's foot care LCDs, destruction of benign lesions and all the rules are there. And it tells us exactly what we need to do. And in many cases, there's a long list of documentation requirements. We are supposed to know. In a case of an audit saying, "I didn't know that", that does not get you off the hook. When you sign the contract, you agreed to follow their rules.

So a lot of docs say, "That's silly. How am I supposed to know that? I'm just going to tell them I never knew." That doesn't work. You are supposed to know the guidelines that are laid out in the LCD. So again, I did not focus just on Noridian because it's a national audience. This is a list of what most of them require. Your LCD might be different. There might be something in yours that's not here. There might be something here that's not in yours, but this is a really good list and it's extensive. And you might say, "That's crazy. How can I put all this in every note? Every ulcer debridement note is going to be a whole bunch of pages if I do all this."

In many cases, these are the rules and they don't care how long it is. You have to have all these stuff there. And I would argue that many of this is good risk management as well. There are a lot of things in here that might seem silly to us but your malpractice carry once you're documenting. And I hate to say it but this is one circumstance where an EHR can be useful, and that you can build a template, right? So one of the things up here is going to be drainage. So you can build a template that prompts you to satisfy all these crazy requirements. Like you could have drainage, colon, serous, sanguineous, purulent, serous sanguineous, bloody, right? Whatever our list of possible drainage options are, and then you circle it or click it.

[24:05]

And by making that long list, it will prompt you to satisfy all these requirements. This first one is very silly to us. Many of the LCDs want you to document why you're doing the debridement. And we say, "What do you mean why? I'm debriding it because it needs it." Like we know why we debride ulcers but if your LCD requirements, that is a good sentence to template, I think, because in many cases, it's the same reason every time, right? So I have a sentence. I made it up. You can copy it or use pieces of it if you want. My sentence says, "This ulcer was debrided in an attempt to decrease bio burden, to try to decrease risk of infection and promote healing."

If somebody said, "Why do you debride an ulcer?" That's my answer and that's in almost every single one of my debridement notes. They want to know why. I think that sentence addresses the why. I gave you some other thoughts here, promote healing, lymph salvage, right? Why do we debride an ulcer? They want the underlying diagnosis, diabetes, arterial disease, neuropathy, whatever it is. Whether anesthesia was used or not, just documenting that they're neuropathic doesn't tell them that you didn't use anesthesia.

So that could be – we normally don't, right? So that could be – that's in my template. Anesthetic was not used, template of that. They want both the size and depth of the ulcer, and separately the size – the amount of tissue removed and the depth of tissue that was removed. Those can be two different things, and hopefully after having going through the coding, it's now very clear why those are two different things and why we have to document both as them being drainage, as being options. The drainage quality and amount of drainage, color of the base.

[26:03]

They want to know if there's necrotic tissue present or absent, and this is a good trick. Some of the LCDs say, "Debridement is not covered if there is not necrotic tissue." So for that LCD, we don't want to document no necrotic tissue and that a debridement was performed. They don't want to hear 100% clean running granular with no necrotic tissue, and that a sharp debridement was performed, if it's an LCD that says debridement isn't covered unless there's a necrotic tissue.

So again, read your LCD. Don't be intimidated by it. When you first open it, it's really long and it looks like it's ridiculous to work your way through. It's not. There's a bunch of legal garbage in there at the beginning, at the end, which you can skip through, and you'll get to the meat of it and see exactly what you need to have in your note.

Some of these again are good risk management things, vascularity, pedal pulses, arterial doppler, whatever you did, and a little miniature up report. They don't want sharp debridement performed with five square centimeters of subcutaneous tissue removed. They want a little up report, like dictated up report, like we do after bunion surgery in a hospital, right? Prep, drape, attention was directed to. This instrument was used. The way we dictate it, it doesn't have to be the length of your outpatient surgery bunion up note, but they want a little – they want a narrative of what was done.

The goals of the debridement. What are the patient goals? Are we trying to heal them? Is this just palliative? Are we just trying to keep it clean for the rest of their life? What are the goals here? We should document whether it's getting better or getting worse. And a lot of this seems silly to us but this is what they're looking for, and this is how you stay out of trouble, right? One from us, and you as my colleagues, if somebody shows up on Monday morning and they say, "I want to see your last 50 ulcer debridement." Then you could say, "Have at it. My stuff's perfect."

[28:08]

And you don't have to worry about it because you're doing all this stuff. Texture of the surrounding tissue and the wound at itself, temperature, whether it's normal or elevated, condition of the surrounding tissue, right? Hyperkeratotic, necrotic, macerated, different options they could be, presence or absence of infection. This is a risk management thing. I've heard from risk management speakers they don't want you to write, no sign of infection. They certainly don't want us to write no SOI. That means nothing. They want, no redness, no heat, no odor, whatever, right? The stuff that would demonstrate that.

Location, of course, where it is, whether there's undermining or tunneling. What instrument you used, scalpel, scissors, curette? That's something else you could template because most of us use the same thing every time depending on what our instrument of choice is. What dressings were used postoperatively? What instructions were given? How you're offloading this ulcer? We mentioned underlying diagnosis, which is probably going to be the same as comorbidity or complicating factors. I think this is a good question to ask your malpractice carrier.

Again, most of the national chain wound centers are insisting on it but this is a good question for malpractice carrier. Most are going to say yes. Should I be taking a picture and document it? There are zero LCDs in the country today that require this, probably coming, right? With the technology that we have, there are no LCDs that require this. There are some national chain wound centers that require it. There are no LCDs that require it but it may be a good risk management tool. I did leave a minute and 40 seconds for questions and would love to take some, please.


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