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Debridement: You Stand to Lose $70 Unless You Report Modifier 59 Appropriately


- Published on Tue, Mar 29, 2016

Tip: Depth of the debridement area holds the key to reimbursement.

If you find coding multiple debridements for the same patient during the same session confusing, here’s expert help. The key to success lies in specificity of documentation and using the correct rules for these minor skin surgeries.

Basically, you’ll have to know how deep the provider goes during the debridements, as it is the key to unlock the door to debridement coding success. If you have this information, you’ll be able to decide when to use modifier 59 (Distinct procedural services) or the appropriate X modifier, and when to select a single code for the entire procedure.

Check out this expert advice on best practices when reporting modifiers with multiple debridements.

Put 59 to Work for Different Treatment Types

Most physician practices will perform two types of debridement in-office. Report 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) if notes indicate that the physician debrides a “surface” wound (down to the epidermis or dermis). Opt for 11043 (Debridement, muscle and/or fascia [includes epidermis, dermis, and subcutaneous tissue, if performed]; first 20 sq cm or less) when the notes indicate that the debridement extended to the muscle/fascia.

“Be very specific about how deep [the provider] went and the square centimeters of the debridement,” Mac advises. If the physician doesn’t detail this in the note, make certain you ask for an addendum to the note to substantiate the appropriate service to bill.

If the patient’s wounds are of differing depths, you’ll report a code for each debridement with modifier 59, confirms Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla.

Note: For payers that prefer you use the X modifiers instead of 59, you would choose one of the following: XE (Separate encounter), XP (Separate practitioner), XS (Separate structure), or XU (Unusual non-overlapping service).

Get Dx Coding Right to Reinforce Claim Strength

When you’re reporting 11043 and 11042-59, Mac recommends making sure your ICD-10 codes “very specific to each part of the body in order to prove that you have two separate places, areas or depths.” Also, make certain each CPT® code is associated with the appropriate diagnoses.

Scenario: Consider this example from Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president of Healthcare Resource Management Inc. in Spring Lake, N.J.:

The physician debrides 15 sq. cm of muscle and fascia on a patient’s left forearm, and then debrides 10 sq cm of subcutaneous tissue on her right forearm. On the claim, you should report 11043 for the left forearm debridement with S51.812A (Laceration without foreign body of left forearm; initial encounter) appended to represent the patient’s wound. Then, you’d report and 11042-59 (or XS) with S51.811A (Laceration without foreign body of right forearm; initial encounter) appended to represent the patient’s injury.

Good idea: If your payer accepts site modifiers, you should append modifier LT (Left side) to 11043 and RT (Right side) to 11042 to further make your case for separate wounds and sites.

Append 59 Properly or Lose Around $70

In order to get as much payment as possible for each multiple debridement, make sure you append modifier 59 to 11042, not 11043. The payer will likely cut reimbursement in half for whichever code you report with modifier 59, and pay 100 percent for the code without a modifier.

Impact: The 11043 code pays about $233 (6.49 total non-facility relative value units [RVUs] multiplied by the 2016 Medicare Physician Fee Schedule rate of 35.8279), while 11042 is worth around $119 (3.31 non-facility RVUs multiplied by 35.8279).

You’ll want the payer to reduce the 11042 pay, not 11043. Total payout for 11043 and 11042-59 is about $293; if you report 11042 and 11043-59, you’ll only garner about $225 for the same service.

Keep Modifiers Away from Same-Depth Debridements

If your physician performs multiple debridements of the same depth for the same patient, “you would add the surface area together and code based on the total surface area,” reports Brink.

Example: The provider debrides a pair of subcutaneous wounds for a patient: one 20 square cm wound on the patient’s right leg, and another 15 square cm left leg injury. On the claim, you would report 11042 for the first 20 sq. cm of debridement space, and 11045 (… each additional 20 sq. cm, or part thereof [List separately in addition to code for primary procedure]) for the remaining treatment area.

You don’t need a modifier for this scenario because the wounds were of the same depth, Brink explains.



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