1. Dermatology Faculty Meeting
January 27, 2011

2. Financial Performance
Efficiency, Growth,
Financial Performance
• 2011 CPT Changes
• Debridements / Wound Care
Dressings / Biological Products
• Global Periods
E&M Documentation

3. Challenges when billing outpatient Wound Care services
Office of Inspector General (OIG) has included wound care services in its annual work plan.
The challenges hospitals and providers face are many including:
Correct code selection
Adequate documentation to support medical necessity.
How to bill specific wound care services.
When to apply modifiers
When to report separately for wound care supplies.

4. 2011 CPT Code changes
The Integumentary System has been expanded to include new guidelines to define wound care and debridement services.
Wound debridements ( ) are reported by depth of tissue that is removed and by the surface area of the wound.
Reported for injuries, infections, wounds and chronic ulcers.

5. Debridement codes 3 New Codes 2011 11045 11046 11047 6 Revised Codes
11010
11011
11012
11042
11043
11044
2 Deleted Codes 2010
11040
11041
New-Cross reference codes
97597 – 97598
skin (epidermis + dermis)
(active wound care
management)

6. Revised CPT codes Debridement of skin (Epidermis and/or dermis only)
97597: for the first 20 sq cm or less
97598: Each additional 20 sq cm
Debridement, subcutaneous tissue (includes epidermis and dermis)
11042: for first 20 sq cm or less
11045: Each additional 20 sq cm.
Debridement, muscle and /or fascia (includes skin and subcutaneous tissues)
11043: for first 20 sq cm or less.
11046: Each additional 20 sq cm.
Debridement, bone (includes muscle, fascia, skin and subcutaneous tissues)
11044: for the first 20 sq cm or less
11047: Each additional 20 sq cm.

7. Active Wound Care Management
It is known as Non-Excisional or Nonsurgical Wound care.
These procedures are performed to remove devitalized and /or necrotic tissue to promote wound healing. These services are billed when an extensive cleaning of a wound is needed prior to the application of dressings or skin substitutes placed on to a wound. Usually performed without the use of anesthesia.
97597 – total wound surface area for the first 20sq cm or less
97598 – each additional 20 sq cm
Note:
Use in conjunction with (used for recurrent wound debridements)
Do not report and in conjunction with surgical debridement codes – for the same wound.

8. Debridement
Debridement is removal of foreign material and /or devitalized or contaminated tissue or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed.
Topical or local anesthesia is billed with codes

9. Selection of debridement codes
Single wound
Report depth using the deepest level of tissue removed.
Example: Bone debrided from 4cm heel ulcer and 10 sq cm ischial ulcer (code 11044).
Multiple wounds
Sum the surface area of those wounds that are at the same depth but do not combine sums from different depths.
Example: When subcutaneous tissue is debrided from a 16sq cm abdominal wound and 10 sq cm thigh wound (11042 for first 20 sq cm and for second 6 sq cm).

10. Documentation requirements for debridement
Medical record should support medical necessity and frequency of the treatment.
Medical record should indicate the
Tissue removal (skin, subcutaneous tissue, muscle, bone).
Method used to debride (i.e., hydrostatic versus sharp versus abrasion methods)
Character of wound
dimensions
description of necrotic material present
description of the tissue removed
degree of epithelialization etc. Before and after treatment.
LCD L3178-MAC–NHIC Corp –MA 1/1/2011.

11. Documentation Requirements
Medical necessity to be met
Documented plan of care and goals.
Clinical circumstances
Progress of wound response to treatment for each service billed.
Current wound size
Wound depth
Presence or absence of obvious signs of infection
Presence & extent of or absence of necrotic, devitalized or non-viable tissue that would inhibit healing or promote adjacent tissue breakdown.

12. Clinical Assessment of Wound
Complete history and physical
Contributing factors (co-morbidities)
Surface Size
Depth
Severity of the wound
Signs of infection/drainage
Extent of infection
Existing conditions that prohibit healing
Previous wound care treatment
Reassessments if does not heal beyond 30 days of treatment.

13. Key Points for Debridement Services
New and Revised Debridement codes effective from 1/1/2011
11042, 11043, 11044, 11045, 11046, depends upon:
Depth of tissue removed
Surface area of the wound
Single wound – deepest level of tissue removed
Multiple Wounds – Sum of surface area that are at the same depth
Documentation always required:
Size, depth, appearance of ulcer, and type of tissue removed.
Medical necessity and frequency of treatment.

14. Dressings
The following HCPCS codes are considered a dressing and therefore bundled into the procedure. (all Q codes Q4104 – Q4121)
For Example:
Q4108 – Integra matrix skin sub.
Q4115 – Alloskin, per square cm.
Q4116 – Alloderm, per square cm.
Q4117 – Hyalomatrix, per square cm.

15. New Codes for Biologic products
Human Skin Equivalents are bioengineered skin products used in wound treatment.
Two new HCPCS codes to be used for Application of Apligraf or Dermagraft to a lower extremity only (effective for services on or after 1/1/2011).
Application of tissue cultured skin substitute or dermal substitute for use of lower limb, includes the site preparation and debridement if performed:
G0440 for first 25 sq cm or less
G0441 each additional 25 sq cm

16. CPT Codes for Biologic products
If the site is other than lower extremity continue using the following CPT codes.
Skin substitute:
15340 for first 25 sq cm or less
15341 for each additional 25 sq cm

17. Global Period
Global surgical package refers to a policy of bundling payment for the various services associated with an operation into a single payment.
CMS identifies specific services included in the global surgical package when provided by the same physician who performs the surgery.
Postoperative follow-up visit (99024), normally included in the surgical package, to indicate that an E/M service was performed during post-op period for a reason related to the original procedure.
99024 is a non-paying code. It should be only used internally to track non-billable follow up services within the postoperative/global period.
“Rounding” on patients within the global period will be part of the global package and should not be billed separately. More details in a later slide.
Billing Compliance Training - Surgery 17

18. Post operative /Global Periods
Medicare assigns post operative global periods of:
zero or 10 days to minor surgeries
0 days for Biopsies, intra-lesional injections, Moh’s
10 days for Minor surgeries (Excisions, destructions, Intermediate /complex repairs, I&D etc…).
Includes E&M services on the day of a minor procedure and during the 10 day postoperative period generally not payable.
90 days to major surgeries
90 days for Major surgeries (flaps and grafts).
Includes E&M services on the day before and/or day of a minor procedure and during the 90 day postoperative period generally not payable.

19. Medicare’s Global Surgical Package
Services considered part of the global surgical fee include:
Preoperative visits after the decision is made to operate beginning with the day before major surgical service and the day of minor surgeries.
Visits during post op period that are related to the recovery from the surgery . These services include:
post op pain management
dressing changes
removal of sutures, staples or drains
local incision care
removal of operative packs
All medical or surgical services due to complications that do not require additional trip to the operating room.
E/M visit unrelated to the procedure can be billed with 24 modifier.

20. Post-operative follow-up care
An established patient E/M visit can be billed with no modifier appended for routine follow up care related to procedures with zero global days, such as:
dressing changes
wound checks
suture removal
99211 is only used if a nurse saw the patient.

21. Evaluation and Management: A Focus on History
ROS (Review of Systems) often under-documented
An inventory of body systems obtained through a series of questions asked of the patient by the provider to identify signs/symptoms experienced by the patient.
It is the number of systems counted, not the number of responses per system
Problem Pertinent (1 System): the system directly related to the problem
Extended (2-9 Systems): the system directly related to the problem AND a limited number of additional systems
Comprehensive (At least 10 systems): the system directly related to the problem plus all additional body systems
Abbreviated Documentation for a Comprehensive Review of Systems:
IF at least 10 systems were reviewed, abbreviated documentation is allowed: Instead of listing each body system, it is permitted to individually list those body systems with positives or pertinent negatives plus the statement:
“all other systems were reviewed and are negative”.
The wording of this phrase is critical to getting credit.

22. Established Patient Visits (2 of 3)
Code & Extent of Work
99213
99214
99215
Expanded Problem Focused
Detailed
Comprehensive
History
HPI = 1-3
ROS = 1
HPI = 4+
ROS = 2-9
PFSH = 1
ROS = 10+
PFSH = 2 of 3
Single Exam
General Multi
Bullets =6
At least 6 Bullets
Bullets = 12
At least 12 bullets
Bullets = 23
2 in 9 systems
MDM
Dx/mgmt = 2
Data = 2
Risk = Low
Low
Dx/mgmt = 3
Data = 3
Risk = Mod
Moderate
Dx/mgmt = >4
Data = >4
Risk = High
High

23. New Patient Visits & Consults (3 of 3)
Code
& Extent of Work
99203 / 99243
99204 / 99244
99205 / 99245
Detailed
Comprehensive
History
HPI = 4+
ROS = 2 - 9
PFSH = 1
ROS = 10 +
PFSH = 3
Single Exam
General
Multi
Bullets =12
At least 12 Bullets
Bullets = 23 in Skin Single System Exam
MDM
Dx/mgmt = 2
Data = 2
Risk = Low
Low
Dx/mgmt = 3
Data = 3
Risk = Mod
Moderate
Dx/mgmt = >4
Data = >4
Risk = High
High

24. 1997 Skin Exam Criteria (slide 1 of 3)
System/Body Area Elements of Examination
Constitutional ∙ Measurement of any three of the following seven vital signs: 1) sitting or
standing blood pressure, 2) supine blood pressure, 3) pulse rate
and regularity, 4) respiration, 5) temperature, 6) height,
7) weight (May be measured and recorded by ancillary staff)
∙ General appearance of patient (e.g.,, development, nutrition, body habitus,
deformities, attention to grooming)
Eyes ∙ Inspection of conjunctivae and lids
ENMT ∙ Inspection of lips, teeth and gums
∙ Examination of oropharynx (e.g., oral mucosa, hard and soft palates,
tongue, tonsils, posterior pharynx)
Neck ∙ Examination of thyroid (e.g., enlargement, tenderness, mass)
Cardiovascular ∙ Examination of peripheral vascular system
by observation (e.g., swelling, varicosities)
and palpation (e.g., pulses, temperature, edema, tenderness)
GI (Abdomen) ∙ Examination of liver and spleen
∙ Examination of anus for condyloma and other lesions
Lymphatic ∙ Palpation of lymph nodes in neck, axillae, groin and/or other location
Extremities ∙ Inspection and palpation of digits and nails (e.g., clubbing, cyanosis,
inflammation, petechiae, ischemia, infections, nodes)

25. 1997 Skin Exam Criteria (slide 2 of 3)
System/Body Area Elements of Examination
Skin • Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest,
pubic area (when indicated) and extremities
Inspection and/or palpation of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas:
• Head, including the face • Back
• Neck • Right upper extremity
• Chest, including breasts and axillae • Left upper extremity
• Abdomen • Right lower extremity
• Genitalia, groin, buttocks • Left lower extremity
NOTE: For the comprehensive level, the examination of at least eight anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of the right upper extremity and the left upper extremity constitutes two elements.
• Inspection of eccrine and apocrine glands of skin and subcutaneous tissue
with identification and location of any hyperhidrosis, chromhidroses or
bromhidrosis
Neurological/ Brief assessment of mental status including:
Psychiatric • Orientation to time, place and person
• Mood and affect (e.g., depression, anxiety, agitation)

26. 1997 Skin Exam Criteria (slide 3of 3)
Content and Documentation Requirements
Level of Exam Perform and Document:
Problem Focused One to five elements identified by a bullet.
Expanded At least six elements identified by a bullet.
Problem Focused
Detailed At least twelve elements identified by a bullet.
Comprehensive Perform all elements identified by a bullet;
• document every element within each System identified inside a border.
• and at least one element in each System/Body Area without a border.

27. Questions ?
Thanks for attending!