Debridements

By Alexander Miller, MD, January 1, 2020

Your patient with an eczematous stasis dermatitis and a superficial stasis ulcer requires debridement of the ulcer to the deep dermis in order to optimize healing. You consider the available debridement CPT® codes and are stumped: Which ones are appropriate?

The CPT manual offers a variety of debridement procedure codes that may seem similar and thus can challenge one’s code selection prowess. “Active Wound Care Management” codes 97597-97602 are described as being “performed to remove devitalized and/or necrotic tissue and promote healing.” Such care includes debridement. However, debridement codes 11000 – 11047 seem to describe some of the same work done in active wound care management. Which codes are best for what circumstances?

It is a bit of a conundrum. The debridement introductory section of the CPT stipulates the following: “Wound debridements (codes 11042-11047)…may be reported for injuries, infections, wounds, and chronic ulcers.” As one delves into the individual code definitions, one discovers greater specificity. Codes 11000 and 11001 are for “debridement of extensive eczematous or infected skin.” Well, that is certainly not the typical stasis ulcer or surgical excision site healing by secondary intention. Progressing further into the debridement code set, one sees codes 11004-11106: “Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection….” Higher numbered codes in the debridement sequence specify debridement of deeper structures, including subcutaneous tissue, muscle fascia and muscle, and bone, in various combinations (codes 11042-11047).

These codes are reported based upon depth and surface area debrided regardless of location. In the case of codes 11042–11047, depth is defined progressively from the skin level down through to the bone while the surface area is defined as each section of 20 sq. cm, or additional part thereof. This code series is for the debridement of wounds when no direct primary closure, such as grafting, is anticipated.

• 11000 Debridement of extensive eczematous or infected skin, up to 10% of body surface

• +11001 each additional 10% of the body surface, 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)

Let’s return to the patient with the stasis ulcer. Debridement of the ulcer consisted of removing devitalized and fibrin-coated tissue with scissors, and possibly curetting the edges and base in order to expose pinker, vascularized dermal tissue ripe for granulating and epithelializing. Irrigation with saline as well as light gauze scrub may have been done. Such care is described in the Active Wound Care Management section of the CPT, codes 97597-97610:

• 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 topical 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)

Active wound care management delineates care done “to remove devitalized and/or necrotic tissue and promote healing.” Furthermore, the October 2016 CPT Assistant states: “Wound debridement codes are intended for acute wounds that are debrided of devitalized tissue, while active wound care management codes are intended for cleansing and promoting healing in chronic wounds. Methods include high-pressure water jet and sharp selective debridement techniques using scissors, scalpel, and/or forceps.” Following this concept, debridement of acutely developed skin wounds would typically be reported with the 11000 CPT code series while debridement of chronic wounds to/into dermis, such as stasis ulcers, would be reported with the 97597-97610 code series.

If you non-selectively enzymatically debride non-viable tissue or employ a population of medical grade leeches for such therapies, there is a CPT code for you: 97605.

• 97605 Removal of devitalized tissue from wound(s), nonselective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session.

Example 1: Your established patient abrades his arm on pavement during a fall from his bicycle. He seeks you out for care, as you are his dermatologist, and the abrasion is a skin injury. You identify foreign material embedded in dermis and remove it under local anesthesia with vigorous saline-soaked gauze abrasion. You report CPT code 11000, as the area debrided constituted less than 10% of body surface area, and the debridement is limited in depth to the dermis.

Answer: Correct. An acute injury is treated/debrided. Consequently, as per CPT Assistant guidelines, one should report the service with an 11000 et seq code series. Furthermore, the debridement introductory language of the CPT states the following: “These services may be reported for injuries, infections, wounds and chronic ulcers.” As the embedded material is the result of an injury, and debridement is done no deeper than dermis, code 11000 appropriately reports the service.

Example 2: While evaluating scalp skin immediately prior to a scheduled photodynamic light therapy (PDT), you spot some keratotic actinic keratoses and debride them with a curette. You report CPT code 11000 for the debridement and code 96573 for the PDT treatment that you initiate.

Answer: Incorrect. Code 96574 alone should be used, as it includes both debridement of actinic keratoses and the PDT treatment. PDT treatments for actinic keratoses destruction are reported with one of three CPT codes:

• 96567 Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s), per day

• 96573 PDT provided by a physician/qualified health care professional, per day

• 96574 Debridement of premalignant hyperkeratotic lesion(s) (i.e., targeted curettage, abrasion) followed with photodynamic therapy by external application of light to destroy premalignant lesion(s) of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drugs provided by a physician/qualified health care professional, per day

Example 3: You assess bilateral supramalleolar stasis ulcers on a Medicare patient, debride fibrin and biofilm and “freshen” the edges with sharp scissors removal of devitalized dermal tissue. You report CPT code 97597 for the left leg ulcer debridement and code 97597.76 for the right leg ulcer treatment.

Answer: Incorrect. Active wound care management CPT codes 97597 and 97598 are based upon the total surface area treated, regardless of the number of individually treated sites. Consequently, when treating multiple sites, one should measure the surface area of each site and then sum the surface areas to determine the proper code(s). In this case, if the first ulcer measured 4 sq. cm in area and the second, 9 sq. cm, the sum would be 13. CPT code 97597 (total wound area 20 sq. cm or less) is appropriate.

Example 4: Following debridement of an entire stasis ulcer you find that its surface area is broader than measured before debridement. You select the active wound care management code (97597 or 97598) based upon the measured surface area following debridement.

Answer: Correct. The CPT Assistant, May 2011 states: “coding is based on the wound measurement taken after the actual debridement is performed.” However, if part of a wound is debrided, then the code selection should be based only upon the surface area of the debridement, and not upon the area of the entire lesion.

Example 5: A deep stasis ulcer is debrided to the level of muscle, 10-sq.-cm area. Since debridement is done through dermis into subcutaneous fat but not into muscle, you report CPT code 11042.

Answer: Correct. When debridement of any type of lesion, whether acute or chronic, penetrates through the dermis into subcutaneous fat or beyond, one should select a code based upon depth and appropriate surface area. In this case, the appropriate CPT code is 11042, Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq. cm or less (CPT Assistant, May 2011).

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