11/29/2016

Coding & Billing Excellus for 11042 with Stage 1 or 2 Pressure Ulcer

I am having trouble getting Excellus to pay for the 11042 with a stage 1 or 2 pressure ulcer... the Podiatry coding book for the 11042 has both of these diagnoses as appropriate diagnosis. Excellus is quoting ICD Manual and AMA CPT manual... originally billed for stage 2 and then they denied that so changed to stage 1 and denied that one too...is there another code that we should be using for debridement of our ulcers

Both of the diagnosis codes that have been billed for pressure ulcers are appropriate for billing. Unfortunately, Excelleus BC/BS does not have a policy, specific for this type of procedure, and the Medicare LCD policy does not specify diagnosis limitations for ulcer debridements. The recommendation is that the service should be re-processed, since a pressure ulcer is a medically necessary condition for an ulcer debridement, or  ask the Blue Cross carrier to specify a medical policy that specifically excludes a state I & II pressure ulcer from being a medically necessary diagnosis.  If Excelleus confirms that their decision should be upheld then you may want to review use of 97597 and 97598 (if needed). Below are the definitions for those 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 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: 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; each additional 20 sq. cm, or part thereof (List separately in addition to code for primary procedure)