—A chance to cut is a chance to cure.

Medical proverb

Non-viable or “devitalized” material within a chronic wound inhibits the development of vascular tissue (granulation), the formation of skin (epithelialization), and enhances bacterial growth while at the same time decreasing resistance to infection. The removal of such material is called “debridement.”

Recognizing the importance of chronic wound debridement, the American Medical Association (AMA) provided CPT®[1] codes to represent the variety of surgical excisional and non-surgical debridements performed, and the Centers for Medicare & Medicaid Services (CMS) assigned payment rates to these codes. In real life, however, wounds must be debrided a caregiver, who must be compensated for their services, or the expertise for this care will not continue to be available. In this article we hope to explore the health-economic and clinical impact of various debridement protocols. To do that, the following questions must be answered:

1. What type of debridement is needed?

2. What type of debridement is performed?

3. What type of debridement is documented?

Types of Debridement: Clinical vs. Coding Considerations

From a clinical standpoint, debridement techniques include the following:

1. Surgical excisional and non-surgical sharp debridements describe the use of instruments, such as scissors, scalpels or curettes to remove devitalized tissue. Although fast, the procedure is also invasive, potentially painful, requires control of bleeding, and may require hospitalization or anesthesia, and must be performed by a qualified professional.

2. Mechanical debridement may include the use of wet-to-dry gauze dressings, water jet, or ultrasonic irrigation. The procedure does not discriminate between viable and non-viable tissue, and unfortunately, despite over-whelming evidence demonstrating the superiority of other methods of debridement, physicians are most likely to choose gauze over other debridement options.

3. Autolytic debridement is the process by which the wound bed clears itself of devitalized tissue using phagocytic cells and proteolytic enzymes (the body’s own natural enzymes) to liquefy necrotic tissue. This is accomplished by keeping the wound moist with occlusive or semiocclusive dressings. The process is selective, but slow, and should be used in patients whose medical and nutritional status are fairly stable. It may also be appropriate for patients on anticoagulant therapy and for whom surgical excisional and non-surgical sharp debridement is contraindicated. It should not be used when the wound is infected.

4. Chemical debridement is the application of topical agents that disrupt or digest extra-cellular proteins. The enzyme collagenase is derived from the fermentation of Clostridium histolyticum, and possesses the unique ability to digest collagen in necrotic tissue. Papain, the proteolytic enzyme from the fruit of carica papaya, is a potent digestant of non-viable protein matter but is harmless to viable tissue. Papain is relatively ineffective as a debriding agent by itself, and so it is usually combined with urea, a substance which denatures proteins.

5. Maggots represent a form of biological debridement, which is relatively painless and specific to necrotic material. Maggot secretions also appear to stimulate wound healing and kill bacteria (even resistant Methicillin-resistant S. aureus strains), but the FDA classifies them as “medical devices,” and patient perception can be a problem. CPT/HCPCS codes are not currently available for this procedure.

The real problem, however, is that the clinical definition of a procedure is not necessarily the same as that used from the standpoint of coding, and this discrepancy can be the primary reason for billing errors. For example, many clinicians assume that a “sharp” debridement is equivalent to a “surgical” debridement; this is not the case. A surgical debridement occurs only if material has been excised.

From a coding standpoint, AMA classifies debridements as surgical excisional, selective, and non-selective. Excisional debridement—the “cutting away” of tissue—includes cutting outside or beyond the wound margin until viable bleeding tissue is encountered, and is considered surgical removal of devitalized tissue, necrosis, or slough. Nevertheless, just because a sharp instrument has been used does not mean that a surgical excisional debridement has been performed. Unless the medical record specifically shows that a surgical excisional debridement has been performed, debridements should be coded with either selective or non-selective codes.

The distinction of whether healthy tissue might be injured is not what is taken into consideration from the standpoint of coding.

Selective vs. Nonselective Debridement

As wound care clinicians, we are taught that the difference between selective and non-selective debridement is based on the potential for, or actual injury to, healthy tissue. However, the distinction of whether healthy tissue might be injured is not what is taken into consideration from the standpoint of coding.

The AMA defines selective debridement as “the removal of specific targeted areas of devitalized or necrotic tissue from a wound (author italics). Depending on the condition of the wound, some tissue preparation may be necessary prior to the use of the selective techniques for debridement. Selective techniques may include the use of scalpels, scissors, and forceps to actually cut and remove tissue along the line of demarcation, separating viable tissue from devitalized (necrotic) tissue…. Other selective debridement techniques could include the use of high-pressure water jets to debride targeted non-viable tissue, the use of enzyme applications, or autolysis (or other selected agents), carefully applied (selectively) to targeted non-viable tissue.”

Non-selective debridement is defined as “the gradual removal (author italics) of loosely adherent areas of devitalized or necrotic tissue from a wound. This technique of removing devitalized tissues includes preparation of the area to be debrided in order to soften and loosen the dead tissue. This can be achieved by irrigating the wound using various hydrotherapy techniques. The actual removal of necrotic tissue through the use of non-selective debridement techniques could involve the use of the whirlpool or pulsatile lavage, wet to dry and wet to moist dressing applications, and/or applications of enzymes, which are all used to facilitate the gradual removal of areas of necrotic tissue. “

It might seem quite confusing to use the same techniques and term their usage different procedures, but the difference is one of time and specificity.

What Debridement Technique Is Needed?

Bearing in mind that multiple debridements are needed for larger and more complex wounds, deciding which technique is needed for a given wound at a given time continues to be the subject of much debate. However, while it is sufficient to say that all debridement techniques might be appropriate in the same patient, at different times, selection will depend on issues such as the type and extent of devitalized tissue present, pain control, infection or bleeding risk, cost, access to care, underlying nutritional status, and a host of other complex factors.

What type of debridement Is Performed?

CPT® codes are “Common Procedural Terminology” codes published annually by the AMA. These standardized codes represent diagnostic and treatment procedures and evaluation and management services provided by physicians, podiatrists, osteopaths, and advanced care practitioners. Hospital-owned outpatient wound care departments (HOPDs) also use these codes to define work performed for patients with chronic wounds.

Although diagnostic and procedure CPT codes have the same meaning when physicians and/or the HOPD submit their claims, evaluation and management (E&M) CPT codes are borrowed to submit claims for HOPD clinic visits, but do not have the same meaning as the physicians’ E&M codes. Physicians must follow either the AMA’s 1995 or 1997 E&M guidelines for selecting the correct code to represent the service performed. Moreover, each HOPD is required to develop its own mapping system and policy for selecting the correct CPT code to represent the HOPD clinic visits that are not represented by a procedure code.

The outpatient prospective payment system (OPPS) is Medicare’s payment system for HOPDs, such as outpatient wound care departments. The OPPS categorizes outpatient visits into groups according to clinical characteristics, typical resource use, and the costs associated with the diagnoses and the procedures performed. These groups are called Ambulatory Payment Classifications (APCs). Procedural and non-procedural (clinic visit) codes are "tracked" to APC groups based on resource utilization and clinical comparability. Each APC group is assigned a Medicare payment rate. Therefore, the APC group determines payment for the HOPD.

Surgical excisional wound debridement codes can be performed and billed only by doctors of medicine, doctors of osteopathy, and doctors of podiatry. Allied health professionals, such as NPs, CNSs, and PAs, can perform and bill only if they are adequately trained and if surgical excisional debridement is within the scope of practice of their State License Act. It should also be noted that the surgical excisional debridement code selected must be based on the type of tissue removed, not the depth or grade of the ulcer or wound.

The AMA recently revised the active wound management CPT codes by adding selective and non-selective debridement codes. These codes should be reported when any wound care professional performs non-surgical selective or non-selective debridement on wounds. Active wound care management involving selective and non-selective debridement techniques to promote healing use CPT codes 97597, 97598, and 97602. Note that a non-MD (or non-ARNP or non-PA) must have an order to perform debridement, even if it is only the removal of non-viable tissue. Many times “standing orders” for debridement are used as part of a therapist’s “evaluation and treatment,” but whenever a non-physician per-forms a debridement, an order for this procedure must be provided by the physician.

The selective and non-selective debridement codes are used when a patient’s wound does not require surgical excisional debridement or if a patient cannot tolerate surgical debridement. The provider is required to have direct (one-on-one) patient contact. Codes 97597, 97598, and 97602 include the application of and the removal of any protective or bulk dressings; these procedures typically involve up to 30 minutes of direct one-on-one contact with the patient. If a dressing change is performed without any active wound procedure as described by these codes, one would not use these codes to describe the service.

One particularly confusing issue is that the use of enzymes is “selective” if carefully applied (selectively) to targeted non-viable tissue, and “non-selective” if their use gradually removes loosely adherent areas of devitalized or necrotic tissue from a wound. The confusion arises, because these definitions are not based on whether any particular enzymatic debridement product is “selective” in its chemical action on the tissue.

For clarification regarding coding, the AMA produces 3 main CPT products: (1) the annual CPT book, (2) The Annual CPT Changes: An Insider’s View (which reviews the changes for the coming year); and (3) a monthly newsletter, the CPT Assistant, written by the CPT Editorial Panel to clarify any issues surrounding the current codes. In reviewing all 3 of these sources, the non-excisional codes appear to have “morphed” somewhat over time, a problem which might not be apparent if a wound professional read only 1 or 2 of these resources each year. Importantly, if you research this area, remember that older documents might not represent current guidelines.

At the moment, my associates and I interpret the current verbiage to state that the high-pressure water jet with/without suction is included in 97597. It also appears clear that the use of a whirlpool is bundled into 97597 and is not separately payable. Earlier documents suggested that enzymatic and autolytic debridement are only included in 97602, but, the very thorough clarifying descriptions of selective and non-selective debridement published in the in May 2002 CPT Assistant lead one to believe that enzymatic and autolytic debridement are selective. The conclusion we really came to is that the AMA needs to be approached for clarification regarding these codes. When we obtain further information about this, we will publish it in a future issue of Today’s Wound Clinic.

What type of Debridement is Documented?

The appropriate type of debridement performed is determined by the needs of the wound. The provider must state exactly “what” and “why” the work is being done and properly document the type of tissue that was excised or debrided; the depth of the excision or debridement; the device, drug, or dressing that was used for the excision or debridement; the size of the wound before and after the excision or debridement; and the condition of the wound after the excision or debridement.

The OIG (Office of the Inspector general) has seen a dramatic increase in the number of Medicare claims submitted for the surgical excisional debridement of wounds. As a result, TrailBlazer Health Enterprises, the Medicare Administrative Carrier (MAC) in Texas was engaged to audit them, and their findings showed that in many cases there was insufficient documentation of clear medical necessity to support the surgical excisional debridement procedures as billed. As a result, TrailBlazer implemented Local Coverage Determinations (LCDs), which provide the following documentation guidelines for debridement:

1. Describe the medical condition, including current treatment diagnosis and all relevant diagnoses, of the patient.

2. Describe the wound sufficiently to document medical necessity for the service, including the size and depth of the wound.

3. Document the presence and extent of or absence of signs of infection and/or the presence and extent or absence of necrotic, devitalized, or non-viable tissue.

4. Describe the method of debridement or wound care prescribed (excisional vs. non-excisional).

5. Include the depth (of tissue) and level of debridement or type of wound care to support the CPT code billed.

7. Document the progress of the wound, including factors that would complicate normal healing, and the response of the wound to treatment.

8. If selective debridement is performed (non-excisional), it is required that the total wound surface area (of all the wounds) be documented in square centimeters.

TrailBlazer’s LCDs also offer several other directives that pertain to surgical debridement:

1. Surgical excisional debridement codes must be based on the type of tissue removed, not on the depth or grade of the ulcer or wound.

2. For example: it would not make sense for a Stage II pressure ulcer (which by definition extends only into the dermis) to require a debridement extending into the muscle. The same is true for a Wagner Grade II diabetic foot ulcer. The level of debridement cannot logically be deeper than the grade or stage of the wound since the billed level is determined by the tissue removed.

3. Surgical debridement will be considered as “not medically necessary” when documentation indicates the wound is without infection, necrosis, or nonviable tissues and has pink-to-red granulated tissue.

4. CPT code 11042 is defined as debridement; skin and subcutaneous tissue. Wound-care providers are using this code incorrectly when they are removing fibrin, which is not skin. To bill the code 11042, TrailBlazer expects the provider to debride skin and subcutaneous tissue.

5. An individual wound would not be expected to be repeatedly debrided of skin and subcutaneous tissue because these tissues do not regrow very quickly.

6. TrailBlazer will cover up to 5 surgical 11043 and/or 11044 surgical debridements per patient per year. Services beyond the fifth 11043 and/or 11044 surgical excisional debridement per patient per year will by payable only upon medical review of records that demonstrate medical reasonableness and necessity.

Take Home Message

Perhaps we need to modernize our medical proverb to read, “To debride is to cure.” Providers need to incorporate advanced procedures into their practices. This allows wound-care professionals to perform whichever debridement technique is most appropriate, regardless of whether it is surgical excisional debridement, or non-surgical maintenance selective/non-selective debridement.

Then wound-care professionals must clearly document the type of debridement that was performed. The documentation should include the method (instruments, modalities, dressings, drugs, etc.) used to debride the wound, the level of tissue removed, and the character of the wound before and after debridement. Remember that documentation needs to paint a clear picture for coders, auditors, payers, and others. Medical necessity is determined not only by what was performed, but by what was documented. Therefore, proper documentation and coding benefits both clinicians and patients.

[1]CPT is a registered trademark of the American Medical Association.