Ulcer Debridement Coding

Question: Are we able to bill CPT15275,  HCPCS Q4186, with CPT 97597 for ulcer debridement of the same area the skin graft was applied plus another ulcer same foot, different site? Should I bill an E+M as well?

Response from Codinghelpline.com:Interesting question with a somewhat confusing answer. Let’s start by making some assumptions. This includes that both ulcers that add up to less than 25sq cm, and that they are on the same location (left foot) and the wound was debrided using a scalpel (sharp debridement). Let's also assume that you have properly documented the medical necessity for the use of CTP and the separate identifying site of the debridement and the physical characteristics of both sites.

The CTP claim is billed with the CPT 15275 (CTP to foot initial 25sq cm on a wound less than or equal to 100sq cm). The Q code representing the CTP applied is then billed. The number of units for the Q code will be represented by the sq cm of material actually applied to the wound. Wastage is not billed.

For the wound being debrided, the appropriate CPT1104X code is billed based on the extent of your sharp debridement. if more than full thickness (including at least subcutaneous tissues) but if just skin you are correct that it is CPT 97597. The CPT 1104X or CPT 97597 code is appended with the Modifier 59. This is to distinguish that the CTP site is different than that of the ulcer debridement. Why? Because according to the policy and CCI, the site receiving the CTP is thought to be ready to receive the CTP with minimal site preparation. Hence, no debridement is allowed to the skin grafting site but to another unrelated site.

Because CTP claims in general are highly audited, be prepared to have part or all of this claim denied. Your operative report needs to clearly distinguish between the two separate sites. It is recommended that you take proper photographs of pre- and post-debridement/skin preparation and grafting, with details of what was done on each site and separate operative reports to distinguish what was done on each site. It is very likely that this claim will be red flagged because it is a CTP claim and there is a CPT 1104X or CPT 97597 code on the claim.

Depending on the carrier being billed,  you may want to consider attaching the operative report electronically (ask your software company about how to do this) or submitting the claim manually. Or if denied, appeal the claim or respond to a recoupment promptly. Despite all your efforts, because the left foot is the site, the carrier may insist that the ulcers are on the same site and still deny the CPT 1104X or CPT 97597. Reconsideration and ALJ may be in your future.

—Paul Kesselman, DPM