Tips for Wound Care Documentation

Erika Stevens, CPC - Senior Professional Physician Coding Specialist Outpatient Coding 1 Comment

Tips for Wound Care Documentation

Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. These services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings. Treatments can include debridement (selective or non-selective), compression therapy, non-disposable wound vac (NPWT), Hyperbaric oxygen therapy (HBO), and more. Patients should be evaluated every 7 days to ensure the plan is working and patient is responding to treatment.

An effective way to manage and treat wounds is detailed documentation.

Debridement

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.

 

Wound debridements (11042-11047) are reported by the depth of tissue that is removed and by surface area of the wound. These services may be reported or injuries, infections, wounds and chronic ulcers.

 

Common Debridement CPT Codes

97597 – Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including typical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

               +97598 – each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

 

11042 – Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

               +11045 – each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

 

11043 - Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

               +11046 – each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

 

11044 - Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

               +11047 – each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

Documentation of wound evaluations should include:

Location: where on the body the wound is located

Wound bed assessment: red, odorous, etc.

Exposed structures: limited to skin breakdown

Wound length (cm), width (cm), depth (cm)

Wound surface area (cm*2), wound volume (cm*2)

Tunneling (cm), undermining (cm)

Drainage amount: moderate

Drainage description: serosanguineous

Non-staged wound description: partial thickness

Tissue exposed pre-procedure: fat/subcutaneous or skin breakdown, muscle, etc.

 

Debridement documentation should include:

Tissue exposed pre-procedure: fat/subcutaneous

Type of debridement: excisional

Level: subcutaneous tissue

Pain control: Lidocaine 2% topical gel

Length (cm), width (cm), depth (cm)

Percent debrided (%): 100

Calc area debrided (cm*2): 2.5

Calc vol (cm*3): 0.25

Tissue and other material debrided: dermis, subcutaneous tissue, debris, exudate and slough

Tissue exposed post-procedure: fat/subcutaneous

Instrument: curette

Amount of bleeding: small

Hemostasis obtained with: pressure

Procedural pain: 0

Post-procedural pain: 0

Response to treatment: Procedure was tolerated well

Post-procedure level of consciousness: Awake and aler

 

CPT 2021 Professional Edition

CMS.gov – Local Coverage Article Billing and Coding: Wound Care (A55818)

 

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