How to be Careful about CPT Coding and Modifiers while working on Wound Care?

The misuse of CPT coding and billing modifiers is widespread and frequently done in the case of wound care practices. This mistake can even make big holes in your pocket once the inaccurately used medical billing modifiers are traced by the insurance company or the third-party payers on a claim. Perhaps you can be expected to return the insured money as well that insurance or third-party payers paid you.

Disappointingly, misused wound care billing modifiers may also trigger an audit that can cost your practice hefty fines. In fact, such audit fines can go up to as high as $10,000 for each mistakenly used modifier on a claim. That’s why an in-depth understanding of codes for wound care services and other documentation requirements is crucial for ensuring accurate reporting. Another easy way out is to outsource wound care medical billing services to an experienced company. 

No matter whether you outsource wound care billing services or hire an in-house team, active wound care management involves the following CPT Codes: 

CPT Codes:

Wounds involving subcutaneous tissue

11042: Used for debridement, subcutaneous tissue (including dermis and epidermis, if performed) for first 20 sq cm or less.

+11045: for each additional 20 sq cm, or part of.

Wounds involving muscle and/or fascia

11043: Used for debridement, muscle, and/or fascia (including dermis and epidermis and subcutaneous tissue, if performed) for the first 20 sq cm or less.

+11046: for each additional 20 sq cm, or part of.

Wounds involving bone

11044: Used for debridement, bone (including dermis and epidermis and subcutaneous tissue, muscle, and/or fascia, if performed) for first 20 sq cm or less.

+11047: for each additional 20 sq cm, or part of.

Evaluation/Re-assessment is Included in Wound Care Service

  • Generally, it is considered to be wrong to report an E/M service in addition to a wound care service (e.g., debridement, suture removal, application of an Unna’s boot, etc.).
  • E/M can be reported additionally if the physician performs and documents a significant and identifiable service separately during the wound care encounter. Also, the E/M service must be distinct from the scheduled visit for the same wound care and require medical evaluation and treatment for the same wound care. 
  • According to modifier 25, the E/M service can be reported separately if the evaluation and management service is done by the same physician or any other trained health care professional on the exact same day of the procedure or any other service.

Documentation Essentials

  • The narration of the wound includes size along with length, width, depth, and total square cm. the appearance, undermining, drainage, character, infection, presence of edema, the disease-causing underlying complications on healing the wound, and other problems related to it. 
  • Description of the things used in the debridement procedure, for example, scalpel, curette, scissors, nippers, etc. 
  • A complete narration of which deepest layer of the tissue was removed in the debridement process, for example, devitalized dermis and/or epidermis, fibrin, subcutaneous tissue, biofilm, exudate, muscle, and/or bone.
  • Post-op care instruction provided on the progress of the wound with the specification of the dressing applied and follow-up notes in brief, future process plans. 
  • Complete narration on wound improvement or any measurable changes like inflammation, pain, swelling, necrotic tissue slough, wound improvement or declination, wound dimension changes, etc. 
  • A complete and precise description of the tissue that has been cut away in the chart notes.
  • A complete description of the steps to address the new condition that might include oral antibiotics, further testing, consultation request for vascular interventions, a biopsy of the wound, and podiatric consultation for off-loading or bracing. 

You must watch out for these coding errors!

According to a recent Medscape article, the most common issues that can initiate claim denials for wound care billing services are:

  • Confusion between whether there is a separately billable service or not, i.e., incorrect use of modifier 25.
  • In the case of wound dimensions for the debrided area, not considering the add-on codes. 
  • Absence of or poorly documented wound dimensions
  • Medical billing service providers for wound care have to be very careful about puzzling between selective and nonselective debridement.
  • Use coding for debridement of multiple layers per site instead of the deepest layer of debridement. As an example, bone and muscle debridement cannot be coded together for the same site. 
  • Coding for change of dressing of wounds separately from an E/M service.

The financial health of any wound care practice depends on revenue cycle management and complete wound care billing solutions. It’s essential to be careful while using modifiers correctly, precisely recording patient records and healthcare provider’s notes, and certifying that the claims are definitely not under or over-coded. This is precisely why you should outsource wound care medical billing services

24/7 Medical Billing Services experts know all about the ins and outs of insurance and third-party payers, acknowledging the prevention of denials and rejections in the first place. In fact, this is the best “cleaning solution” of receiving the revenue quicker. 

Read more: Why Outsourcing Wound Care Billing Can Help Your Practice?

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