by Grant Huang, CPC, CPMA
September 16th, 2016
Wound care can be a tricky arena for auditors, but if there's any one element that providers tend to skimp on, it's wound measurements. Getting wound measurements right is crucial, but providers can sometimes be slapdash with documenting their measurements. Let's review what's required in terms of measurements for the most common wound care procedures, excisional (e.g. 11042) and selective debridement (e.g. 97597).
Getting it right
Wound measurements as part of wound description:
1. The wounds should be numbered when more than one wound is observed and described.
2. Each wound should have measurements of length, width, depth in centimeters.
Wound measurements as part of op note for debridement:
1. The wound measurements should be given both pre- procedure and post-procedure. This indicates whether the procedure expanded the wound margins (helpful in supporting excisional debridement).
2. The total amount of tissue debrided should be listed separately from the wound measurements.
3. The type or types of tissue removed should be listed.
This is also helpful in distinguishing between excisional and selective debridement.
Top mistakes to look for
Now that we've covered proper wound care documentation, let's take a look at some examples where the provider doesn't get it right.
Total amount of tissue debrided isn't specified. The physician records pre-op measurements, but won't list how much tissue was debrided. This is highly problematic when more than one wound is debrided. If there are five wounds but only three are debrided, it's very difficult to audit the debridement codes reported.
Type of tissue removed isn't specified. This can result in the debridement being non-billable. The type or types of tissue removed must always be described.
Wound isn't identified. When the patient has more than one wound (e.g. multiple numbered wounds are described), but the op note simply states "surgical debridement of wounds was undertaken utilizing a #15 scalpel blade ..." then the debridement codes reported cannot be accurately audited.
Units of debridement
The most common debridement codes (11042-11047 for excisional, 97597-97598 for selective) consist of a primary code that covers the first 20 cm2, and then add-on codes that cover each additional 20 cm2. This makes measurements even more crucial to ensure accurate reporting of the number of units.
Any amount of surface over the 20 cm2 limit allows the reporting of an additional unit of the add-on code. For example, if a note for selective debridement states that "20.3 cm2 of tissue was debrided of superficial slough from the right medial calf," this is reported with 97597 and 97598.
Also, remember that there is a maximum daily limit on units of service for all debridement codes. This limit depends on code and on the place of service. The limit is always lower in the outpatient setting, because it would be unusual for such a large surface area to be debrided in the outpatient setting.