L28774-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Wound Debridement Services (L28774)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28774

LCD Title Wound Debridement Services

Contractor's Determination Number A11000

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 01/01/2011

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 100

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.5.1.4 CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20

Indications and Limitations of Coverage and/or Medical Necessity

Debridement is the removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound. Debridement promotes wound healing by reducing sources of infection and other mechanical impediments to healing.

Medicare will consider debridement services medically reasonable and necessary when they are provided for the management of wounds and ulcers of the skin and underlying tissue to promote optimal wound healing or to prepare sites for appropriate surgical intervention. The requirements for reasonable and necessary service(s) include safe and effective debridement methods most appropriate to the type of wound, furnished in the appropriate setting, and ordered and/or performed by qualified personnel.

Skin Debridement (CPT codes 11000-11001)

CPT codes 11000 and 11001 describe removal of extensive eczematous or infected skin. Conditions that may require debridement of large amounts of skin include: rapidly spreading necrotizing process (sometimes seen with aggressive streptococcal infections), severe eczema, bullous skin diseases, extensive skin trauma (including large abraded areas with ground-in dirt), or autoimmune skin diseases (such as pemphigus).

CPT code 11001 is not appropriate for debridement of a localized amount of tissue normally associated with a circumscribed lesion. Examples of this are ulcers, furnucles, and localized skin infections.

Surgical Debridement (CPT codes 11042-11047)

Surgical debridement occurs only if material has been excised and is typically reported for the treatment of a wound to clear and maintain the site free of devitalized tissue including necrosis, eschar, slough, infected tissue, abnormal granulation tissue etc., to the margins of viable tissue. Surgical excision includes going slightly beyond the point of visible necrotic tissue until viable bleeding tissue is encountered in some cases. The use of a sharp instrument does not necessarily substantiate the performance of surgical excisional debridement. Unless the medical record shows that a surgical excisional debridement has been performed, debridements should be coded with either selective or non-selective codes (97597, 97598, or 97602).]

Surgical debridement codes (11042-11047), as performed by physicians and qualified non-physician practitioners licensed by the state to perform those services,are reported by depth of tissue removed and by surface area of the wound. These codes can be very effective but represent extensive debridement, often painful to the patient, and could require complex, surgical procedures and sometimes require the use of general anesthesia. 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.

Documentation for surgical debridement procedures should include the indications for the procedure, the type of anesthesia if and when used, and the narrative of the procedure that describes the wounds, as well as the details of the debridement procedure itself. The CPT code selected should reflect the level of debrided tissue (e.g.,skin, subcutaneous tissue, muscle and/or bone), not the extent, depth, or grade of the ulcer or wound. For example, CPT code 11042 defined as “Debridement, subcutaneous tissue” should be used if only necrotic subcutaneous tissue is debrided, even though the ulcer or wound might extend to the bone. In addition, if only fibrin is removed, this code would not be billed.

It would not be expected that an individual wound would be repeatedly debrided of skin and subcutaneous tissue because these tissues do not regrow very quickly.

Active Wound Care Management

Debridement is indicated whenever necrotic tissue is present on an open wound. Debridement may also be indicated in cases of abnormal wound healing or repair. Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue. This procedure includes wound assessment; debridement; application of ointments, creams, sealants, and other wound coverings; and instructions for ongoing care. It should be billed no more than once per day, regardless of the number of wounds.

Selective Debridement (97597 and 97598)

CPT codes 97597 and 97598 are used for the removal of specific, targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue. Occasional bleeding and pain may occur. The routine application of a topical or local anesthetic does not elevate active wound care management to surgical debridement. Selective debridement includes:

• Selective removal of necrotic tissue by sharp dissection including scissors, scalpel, and forceps

• Selective removal of necrotic tissue by high pressure water jet

Medicare coverage for wound care on a continuing basis for a given wound in a given patient is contingent upon evidence documented in the patient’s medical record that the wound is improving in response to the wound care being provided. It is neither reasonable nor medically necessary to continue a given type of would care if evidence of wound improvement cannot be shown.

Evidence of improvement includes, but is not limited to, measurable changes in at least some of the following:

• Drainage (color, amount, consistency)

• Inflammation

• Swelling

• Pain

• Wound dimensions (diameter, depth, tunneling)

• Granulation tissue

• Necrotic tissue/slough

Such evidence must be documented with each visit. A wound that shows no improvement after 30 days requires a new approach, which may include a reassessment, by a qualified professional, of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new plan of care or treatment method.

In rare instances, the goal of wound care provided in the outpatient setting may only be to prevent progression of the wound, which, due to severe underlying debility or other factors such as inoperability, is not expected to improve.

LIMITATIONS

FCSO Medicare doesnot consider the following services to be wound debridement:

• Removal of necrotic tissue by cleansing, scraping (other than by a scalpel or a curette), chemical application, and wet-to-dry dressing.

• Washing bacterial or fungal debris from lesions.

• Removal of secretions and coagulation serum from normal skin surrounding an ulcer.

• Dressing of small or superficial lesions.

• Removal of fibrinous material from the margin of an ulcer.

• Paring or cutting of corns or non-plantar calluses. Skin breakdown under a dorsal corn that begins to heal when the corn is removed and shoe pressure eliminated is not considered an ulcer and does not require debridement unless there is extension into the subcutaneous tissue.

• Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, or destruction of warts. Providers should report these procedures, when they represent covered, reasonable and necessary services, using appropriate CPT or HCPCS codes.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient

022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

071x Clinic - Rural Health

074x Clinic - Outpatient Rehabilitation Facility (ORF)

075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0360 Operating Room Services - General Classification 0361 Operating Room Services - Minor Surgery

042X Physical Therapy - General Classification 043X Occupational Therapy - General Classification 045X Emergency Room - General Classification

049X Ambulatory Surgical Care - General Classification 051X Clinic - General Classification

052X Free-Standing Clinic - General Classification 0761 Specialty Services - Treatment Room

CPT/HCPCS Codes

11000 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE

11001 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; 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

11043 DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS

11044 DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS

DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH 11045 ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY

PROCEDURE)

DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, 11046 IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO

CODE FOR PRIMARY PROCEDURE)

DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR 11047 FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN

ADDITION TO CODE FOR PRIMARY PROCEDURE)

DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED

97597 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

DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED

97598 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; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

ICD-9 Codes that Support Medical Necessity

040.0 GAS GANGRENE

110.0 - 110.9 opens

in new window DERMATOPHYTOSIS OF SCALP AND BEARD - DERMATOPHYTOSIS OF UNSPECIFIED SITE

440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION

440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE

443.9 PERIPHERAL VASCULAR DISEASE UNSPECIFIED

454.0 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER

454.2 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER AND INFLAMMATION

569.41 ULCER OF ANUS AND RECTUM

608.4 OTHER INFLAMMATORY DISORDERS OF MALE GENITAL ORGANS

608.83 VASCULAR DISORDERS OF MALE GENITAL ORGANS

681.00 - 681.9 UNSPECIFIED CELLULITIS AND ABSCESS OF FINGER - CELLULITIS AND ABSCESS OF UNSPECIFIED DIGIT

682.0 - 682.9 CELLULITIS AND ABSCESS OF FACE - CELLULITIS AND ABSCESS OF UNSPECIFIED SITES

684 IMPETIGO

686.00 - 686.9 PYODERMA UNSPECIFIED - UNSPECIFIED LOCAL INFECTION OF SKIN AND SUBCUTANEOUS

TISSUE

692.1 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO DETERGENTS

692.2 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO OILS AND GREASES

692.3 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO SOLVENTS

692.4 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO DRUGS AND MEDICINES IN CONTACT WITH SKIN

692.5 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO OTHER CHEMICAL PRODUCTS

692.6 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO FOOD IN CONTACT WITH SKIN

692.7 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO PLANTS (EXCEPT FOOD)

692.81 - 692.89 DERMATITIS DUE TO COSMETICS - CONTACT DERMATITIS AND OTHER ECZEMA DUE TO OTHER SPECIFIED AGENTS

692.9 CONTACT DERMATITIS AND OTHER ECZEMA UNSPECIFIED CAUSE

707.00 - 707.9 PRESSURE ULCER, UNSPECIFIED SITE - CHRONIC ULCER OF UNSPECIFIED SITE

709.4 FOREIGN BODY GRANULOMA OF SKIN AND SUBCUTANEOUS TISSUE

709.8 OTHER SPECIFIED DISORDERS OF SKIN

728.86 NECROTIZING FASCIITIS

730.10 - 730.19 CHRONIC OSTEOMYELITIS SITE UNSPECIFIED - CHRONIC OSTEOMYELITIS INVOLVING MULTIPLE SITES

785.4 GANGRENE

870.1 LACERATION OF SKIN OF EYELID AND PERIOCULAR AREA

870.2 LACERATION OF EYELID FULL-THICKNESS NOT INVOLVING LACRIMAL PASSAGES

870.3 LACERATION OF EYELID INVOLVING LACRIMAL PASSAGES

872.00 - 872.02 OPEN WOUND OF EXTERNAL EAR UNSPECIFIED SITE UNCOMPLICATED - OPEN WOUND OF AUDITORY CANAL UNCOMPLICATED

872.10 - 872.12 OPEN WOUND OF EXTERNAL EAR UNSPECIFIED SITE COMPLICATED - OPEN WOUND OF AUDITORY CANAL COMPLICATED

873.1 OPEN WOUND OF SCALP WITHOUT COMPLICATION

873.2 OPEN WOUND OF SCALP COMPLICATED

873.20 - 873.29 OPEN WOUND OF NOSE UNSPECIFIED SITE UNCOMPLICATED - OPEN WOUND OF MULTIPLE SITES UNCOMPLICATED

873.30 - 873.39 OPEN WOUND OF NOSE UNSPECIFIED SITE COMPLICATED - OPEN WOUND OF MULTIPLE SITES COMPLICATED

873.40 - 873.49 OPEN WOUND OF FACE UNSPECIFIED SITE UNCOMPLICATED - OPEN WOUND OF OTHER AND MULTIPLE SITES UNCOMPLICATED

873.50 - 873.59 OPEN WOUND OF FACE UNSPECIFIED SITE COMPLICATED - OPEN WOUND OF OTHER AND MULTIPLE SITES COMPLICATED

873.60 OPEN WOUND OF MOUTH UNSPECIFIED SITE UNCOMPLICATED

873.61 OPEN WOUND OF BUCCAL MUCOSA UNCOMPLICATED

873.70 OPEN WOUND OF MOUTH UNSPECIFIED SITE COMPLICATED

873.71 OPEN WOUND OF BUCCAL MUCOSA COMPLICATED

873.72 OPEN WOUND OF GUM (ALVEOLAR PROCESS) COMPLICATED

873.74 OPEN WOUND OF TONGUE AND FLOOR OF MOUTH COMPLICATED

873.75 OPEN WOUND OF PALATE COMPLICATED

873.79 OPEN WOUND OF OTHER AND MULTIPLE SITES COMPLICATED

873.8 OTHER AND UNSPECIFIED OPEN WOUND OF HEAD WITHOUT COMPLICATION

873.9 OTHER AND UNSPECIFIED OPEN WOUND OF HEAD COMPLICATED

874.00 - 874.9 OPEN WOUND OF LARYNX WITH TRACHEA UNCOMPLICATED - OPEN WOUND OF OTHER

AND UNSPECIFIED PARTS OF NECK COMPLICATED

875.0-875.1 OPEN WOUND OF CHEST (WALL) WITHOUT COMPLICATION - OPEN WOUND OF CHEST (WALL) COMPLICATED

876.0 - 876.1 OPEN WOUND OF BACK WITHOUT COMPLICATION - OPEN WOUND OF BACK COMPLICATED

877.0-877.1 OPEN WOUND OF BUTTOCK WITHOUT COMPLICATION - OPEN WOUND OF BUTTOCK COMPLICATED

878.0-878.9 OPEN WOUND OF PENIS WITHOUT COMPLICATION - OPEN WOUND OF OTHER AND UNSPECIFIED PARTS OF GENITAL ORGANS COMPLICATED

879.0-879.9 OPEN WOUND OF BREAST WITHOUT COMPLICATION - OPEN WOUND(S) (MULTIPLE) OF UNSPECIFIED SITE(S) COMPLICATED

880.00 - 880.29 OPEN WOUND OF SHOULDER REGION WITHOUT COMPLICATION - OPEN WOUND OF MULTIPLE SITES OF SHOULDER AND UPPER ARM WITH TENDON INVOLVEMENT

881.00 - 881.2 OPEN WOUND OF FOREARM WITHOUT COMPLICATION - OPEN WOUND OF WRIST WITH TENDON INVOLVEMENT

882.0-882.2 OPEN WOUND OF HAND EXCEPT FINGERS ALONE WITHOUT COMPLICATION - OPEN WOUND OF HAND EXCEPT FINGERS ALONE WITH TENDON INVOLVEMENT

883.0-883.2 OPEN WOUND OF FINGERS WITHOUT COMPLICATION - OPEN WOUND OF FINGERS WITH TENDON INVOLVEMENT

884.0-884.2 MULTIPLE AND UNSPECIFIED OPEN WOUND OF UPPER LIMB WITHOUT COMPLICATION - MULTIPLE AND UNSPECIFIED OPEN WOUND OF UPPER LIMB WITH TENDON INVOLVEMENT

885.0-885.1 TRAUMATIC AMPUTATION OF THUMB (COMPLETE)(PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF THUMB (COMPLETE)(PARTIAL) COMPLICATED

886.0 - 886.1 TRAUMATIC AMPUTATION OF OTHER FINGER(S) (COMPLETE) (PARTIAL) WITHOUTCOMPLICATION - TRAUMATIC AMPUTATION OF OTHER FINGER(S) (COMPLETE) (PARTIAL) COMPLICATED

887.0 - 887.7 TRAUMATIC AMPUTATION OF ARM AND HAND (COMPLETE) (PARTIAL) UNILATERAL BELOW ELBOW WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF ARM AND HAND

(COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED

890.0-890.2 OPEN WOUND OF HIP AND THIGH WITHOUT COMPLICATION - OPEN WOUND OF HIP AND THIGH WITH TENDON INVOLVEMENT

891.0-891.2 OPEN WOUND OF KNEE LEG (EXCEPT THIGH) AND ANKLE WITHOUT COMPLICATION - OPEN WOUND OF KNEE LEG (EXCEPT THIGH) AND ANKLE WITH TENDON INVOLVEMENT

892.0-892.2 OPEN WOUND OF FOOT EXCEPT TOE(S) ALONE WITHOUT COMPLICATION - OPEN WOUND OF FOOT EXCEPT TOE(S) ALONE WITH TENDON INVOLVEMENT

893.0-893.2 OPEN WOUND OF TOE(S) WITHOUT COMPLICATION - OPEN WOUND OF TOE(S) WITH TENDON INVOLVEMENT

895.0-895.1 TRAUMATIC AMPUTATION OF TOE(S) (COMPLETE) (PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF TOE(S) (COMPLETE) (PARTIAL) COMPLICATED

896.0 - 896.3 TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) UNILATERAL WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) BILATERAL

COMPLICATED

897.0 - 897.7 TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL BELOW KNEE

941.20 - 941.29 * BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FACE AND HEAD UNSPECIFIED SITE - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE)

OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK

941.30 - 941.39 * FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF FACE AND HEAD - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK

941.40 - 941.49* UNSPECIFIED SITE OF FACE AND HEAD WITHOUT LOSS OF BODY PART - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK WITHOUT LOSS OF A BODY PART

942.20 - 942.29 * BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF UNSPECIFIED SITEOF TRUNK - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK

942.30 - 942.39 * FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF TRUNK - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF OTHER AND MULTIPLE SITES OF TRUNK

942.40 - 942.49* DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OFTRUNK UNSPECIFIED SITE WITHOUT LOSS OF BODY PART - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK WITHOUT LOSS OF BODY PART

943.20 - 943.29 * BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF UNSPECIFIED SITE OF UPPER LIMB - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND

943.30 - 943.39 * FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE

OF UPPER LIMB - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF

MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND

943.40 - 943.49* DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF UPPER LIMB WITHOUT LOSS OF A BODY PART - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND WITHOUT LOSS OF UPPER LIMB

944.20 - 944.28* BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF UNSPECIFIED SITE OF HAND - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF WRIST(S) AND HAND(S)

944.30 - 944.38* FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF HAND - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF WRIST(S) AND HAND(S)

944.40 - 944.48* DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF HAND WITHOUT LOSS OF HAND - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF WRIST(S) AND HAND(S) WITHOUT LOSS OF A BODY PART

945.20 - 945.29 * BLISTERS EPIDERMAL LOSS (SECOND DEGREE) OF UNSPECIFIED SITE OF LOWER LIMB (LEG) - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF LOWER LIMB(S)

945.30 - 945.39 * FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF LOWER LIMB - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF LOWER LIMB(S)

945.40 - 945.49* DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF LOWER LIMB (LEG) WITHOUT LOSS OF A BODY PART - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF LOWER LIMB(S) WITHOUT LOSS OF A BODY PART

946.2 * BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SPECIFIED SITES

946.3 * FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SPECIFIED SITES

946.4 * DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SPECIFIED SITES WITHOUT LOSS OF A BODY PART

958.3 POSTTRAUMATIC WOUND INFECTION NOT ELSEWHERE CLASSIFIED

997.60 UNSPECIFIED LATE COMPLICATION OF AMPUTATION STUMP

997.62 INFECTION (CHRONIC) OF AMPUTATION STUMP

998.30 - 998.33 DISRUPTION OF WOUND, UNSPECIFIED - DISRUPTION OF TRAUMATIC INJURY WOUND REPAIR

998.59 OTHER POSTOPERATIVE INFECTION

998.83 NON-HEALING SURGICAL WOUND

* These additional ICD-9-CM codes are to be used with CPT codes 97597 and 97598 only.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the performing provider must clearly indicate the medical necessity of the service being billed. The medical record must include the following information and be available to Medicare upon request:

• An operative note or procedure note for the debridement service(s). This note should describe the anatomical location treated, the instruments used, anesthesia used if required, the type of tissue removed from the wound, the depth and area of the wound and the immediate post-op care and follow-up instructions.

• Identification of the wound location, size, depth and stage by description and/or a drawing or photograph.

• A description of the type(s) of tissue involvement, the severity of tissue destruction, undermining or tunneling, necrosis, infection or evidence of reduced circulation.

• A pathology report when billing for the debridement procedure described by CPT code 11044.

In addition, except for patients with compromised healing due to severe underlying debility or other factors, documentation in the medical record must show:

• The status of the wound is such that the treatment is expected to make a significant practical improvement in the wound in a reasonable and generally predictable period of time.

• There is an expectation that the treatment will substantially affect tissue healing and viability, reduce or control tissue infection, remove necrotic tissue or prepare the tissue for surgical management.

• The patient’s expected restoration potential must be significant in relation to the extent and duration of treatment required in achieving this potential. If wound closure is not a goal, then the expectation is to optimize recovery and establish an appropriate non-skilled maintenance program.

Active wound care management performed by a physical or occupational therapist must be performed under a certified plan of care as any other therapy service outlining specific goals, duration, frequency, modalities, an anticipated endpoint, and other pertinent factors as they may apply. Departure from this plan must be documented.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

The appropriate interval and frequency of debridement depends on the individual clinical characteristics of patients and the extent of the wound. Reduction of pressure and/or control of infection will facilitate healing and may reduce the need for repeated debridement services. The treatment plan for a patient who requires frequent repeated debridement should be reevaluated to ensure that pressure reduction and infection control have been adequately addressed.

Debridement services are not considered to be medically necessary when performed more frequently than once a week. The rationale and medical justification for more frequent services must be clearly documented in the medical record. If the debridement of chronic ulcers require more than eight total services for any of the debridement codes listed in the LCD (CPT codes 11000-97598, the rationale and medical justification for this

utilization, on a given day or over time, must be specifically addressed in the medial record.

Sources of Information and Basis for Decision

Ayello, E., & Cuddigan, J. (2004). Debridement: Controlling the necrotic/cellular burden. Advances in Skin & Wound Care, 17:66-78.

Black, J., Baharestani, M., Cuddigan, J., Dorner, B., Edsberg, L., Langemo, D., & et al. (2007). National pressure ulcer advisory panel’s updated pressure ulcer staging system. Dermatolgy Nursing. 19(4): 343-349.

Choucair, M. M., Fivenson, D. P. (2001). Leg ulcer diagnosis and management. Retrieved March 19, 2002 from http://homeconsult.com/das/article/body/1/jorg=journal&source=MI&sp=12040563&sid This reference provided information surrounding appropriate diagnoses criteria.

CPT Assistant – June 2005 & October 2007

CPT Changes: An Insider’s View – 2005, & 2008, 2011 Debridement. (2004). Body1, Inc. Retrieved October 6, 2008 from

http://www.wounds1.com/procedure20.cfm/19

Deery, H. G., & Sangererozan, J. A. (2001). Saving the diabetic foot with special reference to the patient with chronic renal failure. Retrieved March 19, 2002 from http://home.mdconsult.com/das/article/body/1/jorg=journal&source=MI&sp=11974766&sid This reference provided definitions and indications for wound management.

Fife, C. (2008). The debridement predicament. Retrieved October 6, 2008 from: http://www.intellicure.com/News/2008_01-02_Pulse/debridement _predicament.htm

Lewis, R., Whiting, P., ter Riet, G., O’Meara S., & Glanville, J. (2001). A rapid and systemic review of the clinical effectiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary intention. Retrieved March 19, 2002 from http://home.mdconsult.com/das/citation/body/jorg=journal&source=MI&sp=11892394&sid This reference provided expectations of treatments for wounds.

Other Medicare Contractors’ LCDs.

Paquette, D., & Fatanga, V. (2002). Leg ulcers. Retrieved March 19, 2002 from http://home.mdconsult.com/das/article/body/1/jorg=journal&source=&sp=12074980&sid This reference provided descriptions and treatments for leg wounds.

Salcido, R., & Popescu, A. (2006). Pressure ulcers and wound care. Retrieved October 1, 2008 from : http://www.emedicine.com/pmr/TOPIC179.HTM

Schaum, K. (2006). Newly funded selective and non-selective debridement CPT codes: Impact on hospital- opwned outpatient wound care departments. Healthpoint, Inc. Retrieved October 1, 2008 from: http://www.woundsresearch.com/docs/Healthpoint_August.pdf

Stillman, R. (2008). Diabetic ulcers. Retrieved October 2, 2008 from : http://www.emedicine.com/med/TOPIC551.HTM

Suzuki, K. & Cowan, L. (2009). Current concepts in wound debridement. Podiatry Today, 22(7) July 1.

Tatsioni, A., Balk, E., O’Donnell, T., Lau, J. (2007). Usual care in the management of chronic wounds: A review of the recent literature. Journal of the American College of Surgeons, 205(4).

Ulcer. (2008). New World Encyclopedia. Retrieved October 2, 2008 from http://www.newworldencyclopedia.org/entry/Ulcer?oldid=683900

Valencia, I., Falabella, A., Kirsner, R. S., & Eaglstein, W. E. (2001). Chronic venous insufficiency and venous leg ulceration. Retrieved March 19, 2002 from http:/home.mdconsult.com/das/article/body/1/jorg=journal&source=MI&sp=11546251&sid This reference

defined and discussed debridement and other treatment modalities. Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with the advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 01/01/2011

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:01/01/2011 Revised Effective Date: 01/01/2011

LCR A2011-001

December 2010 Bulletin

Explanation of Revision: Annual 2011 HCPCS Update. Descriptors revised for CPT codes 11042, 11043, 11044, 97597, & 97598. CPT codes 11040 and 11041 were deleted and CPT codes 11045, 11046, and 11047 were added. Verbiage under the “Surgical Debridement” section of the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD was revised. In addition, the “Sources of Information and Basis for Decision” section was updated, and the following ICD-9-CM codes and code ranges were added: 885.0-885.1; 886.0-886.1; 887.0-887.7; 895.0-895.1; 896.0-896.3; 897.0-897.7; 997.60, and 997.62. The effective

date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:06/01/2009 Start Date of Notice Period:08/15/2009 Revised Effective Date: 09/30/2009

LCR A2009-073

Explanation of Revision: Revisions to the LCD were made in the following sections: Under the “LCD Title” section, the title was changed to “Wound Debridement Services,” under the “Indications and Limitations of Coverage and/or Medical Necessity” section, verbiage was added/deleted under the following sub headings: “Skin Debridement (CPT codes 11000-11001),” “Surgical Debridement (CPT Codes 11040-11044),” and “Active Wound Care Management”. Added “LIMITATIONS” section to the LCD, and verbiage was updated for the “Documentation Requirements” and “Utilization Guidelines” sections. In addition, the “Sources of Information and Basis for Decision” section was updated. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Original Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28774) replaces LCD L18913 as the policy in notice. This document (L28774) is effective on 02/16/2009.

8/10/2009 - The description for Revenue code 0761 was changed 8/1/2010 - The description for Bill Type Code 12 was changed

8/1/2010 - The description for Bill Type Code 13 was changed

8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 71 was changed 8/1/2010 - The description for Bill Type Code 74 was changed 8/1/2010 - The description for Bill Type Code 75 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0360 was changed 8/1/2010 - The description for Revenue code 0361 was changed 8/1/2010 - The description for Revenue code 0420 was changed 8/1/2010 - The description for Revenue code 0421 was changed 8/1/2010 - The description for Revenue code 0422 was changed 8/1/2010 - The description for Revenue code 0423 was changed 8/1/2010 - The description for Revenue code 0424 was changed 8/1/2010 - The description for Revenue code 0429 was changed 8/1/2010 - The description for Revenue code 0430 was changed 8/1/2010 - The description for Revenue code 0431 was changed 8/1/2010 - The description for Revenue code 0432 was changed 8/1/2010 - The description for Revenue code 0433 was changed 8/1/2010 - The description for Revenue code 0434 was changed 8/1/2010 - The description for Revenue code 0439 was changed 8/1/2010 - The description for Revenue code 0450 was changed 8/1/2010 - The description for Revenue code 0451 was changed 8/1/2010 - The description for Revenue code 0452 was changed 8/1/2010 - The description for Revenue code 0456 was changed 8/1/2010 - The description for Revenue code 0459 was changed 8/1/2010 - The description for Revenue code 0490 was changed 8/1/2010 - The description for Revenue code 0499 was changed 8/1/2010 - The description for Revenue code 0510 was changed 8/1/2010 - The description for Revenue code 0511 was changed 8/1/2010 - The description for Revenue code 0512 was changed 8/1/2010 - The description for Revenue code 0513 was changed 8/1/2010 - The description for Revenue code 0514 was changed 8/1/2010 - The description for Revenue code 0515 was changed 8/1/2010 - The description for Revenue code 0516 was changed 8/1/2010 - The description for Revenue code 0517 was changed 8/1/2010 - The description for Revenue code 0519 was changed 8/1/2010 - The description for Revenue code 0520 was changed 8/1/2010 - The description for Revenue code 0521 was changed 8/1/2010 - The description for Revenue code 0522 was changed 8/1/2010 - The description for Revenue code 0523 was changed 8/1/2010 - The description for Revenue code 0524 was changed 8/1/2010 - The description for Revenue code 0525 was changed 8/1/2010 - The description for Revenue code 0526 was changed

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

11042 descriptor was changed in Group 1 11043 descriptor was changed in Group 1 11044 descriptor was changed in Group 1 97597 descriptor was changed in Group 1 97598 descriptor was changed in Group 1

11/21/2010 - The following CPT/HCPCS codes were deleted: 11040 was deleted from Group 1

11041 was deleted from Group 1

Reason for Change