WPS Government Health Administrators (GHA) is a Medicare Administrative Contractor (MAC) and its Local Coverage Determination (LCD) on Wound Care became effective on April 16, 2018. The U.S. states impacted by the WPS LCD on Wound Care are:
- Jurisdiction 5 (J5) – providing both Part A and Part B Medicare benefit administration for Iowa, Kansas, Missouri, and Nebraska, as well as Part A Medicare benefit administration for J5 National providers
- Jurisdiction 8 (J8) – providing both Part A and Part B Medicare benefit administration for Indiana and Michigan
The WPS Wound Care LCD removed coverage for debridement of chronic non-pressure ulcers when the severity is classified as “limited to breakdown of skin.” If a physician removes necrotic tissue they can no longer bill an open wound debridement (e.g. 97597 /97598).
We now need a history lesson. A decade ago we discussed what changed when new debridement codes were implemented. In 2010, the AMA CPT ® Codes for “Excisional Surgical Debridement” were:
- 11040: Partial thickness skin
- 11041: Skin and subcutaneous tissue
- 11042: Full thickness skin
- 11043: Skin, subcutaneous tissue, and muscle
- 11044: Skin, subcutaneous tissue, muscle and bone
In 2010, the AMA CPT ® Codes for NON surgical debridement of necrotic tissue (called “selective debridement”) were:
- 97597: Removal of devitalized tissue from wound(s), selective debridement, without anesthesia, per session; total wound(s) surface area less than or equal to 20 sq cm.
- 97598: Removal of devitalized tissue from wound(s), selective debridement, without anesthesia, per session; total wound(s) surface greater than 20 sq cm.
In other words, before 2011, the codes 97597 and 97598 specifically were for necrotic or devitalized tissue but were NOT considered surgical debridement. In 2011, the AMA panel deleted the codes for “skin-only” debridement (11040 and 11041) and replaced them with codes 97579 and 97598, but changed the definition of those codes. While 97597 and 97598 still represented the debridement of devitalized skin and debris, the new codes became part of the “sharp” debridement code set. The old codes 11042, 11043, and 11044 still defined debridement by depth, but were no longer billed per wound but rather by the first 20 cm2 of wound surface area debrided, and new codes were added which were paired with those codes to describe debridement of additional wound surface area at the same depth.
2011 Revision to the AMA CPT Debridement Codes:
- 97597: Debridement of open wound, i.e., fibrin, devitalized epidermis and/or dermis, exudate, fibrin, biofilm (1st 20 sq cm)
- 97598: Debridement of open wound, i.e., fibrin, devitalized epidermis and/or dermis, exudate, fibrin, biofilm (each addl 20 sq cm)
- 11042: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed), first 20 sq cm or less
- 11043: Debridement, muscle (includes epidermis, dermis, and subcutaneous tissue, if performed), first 20 sq cm or less
- 11043: Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscles and/or fascia, if performed, first 20 sq cm or less
That means, in the 2011 revision to the debridement codes, we lost the code for debridement of skin unless it was “devitalized.” The new WPS policy states you can NOT use 97597/97598 for debridement of necrotic skin. However, since the definition of these codes IS removal of “devitalized” skin, it would appear that you can’t use those codes at all.
WPS also identifies conditions which must be present and documented in order for a debridement to be covered. The list includes neuropathic and neuroischemic ulcers as being covered for debridement but does not specifically identify diabetic ulcers. The policy states that for debridement to be covered, at least ONE of the following conditions must be present and documented:
- Pressure ulcers, Stage III or IV
- Venous or arterial insufficiency ulcers
- Dehisced wounds
- Wounds with exposed hardware or bone
- Neuropathic ulcers
- Neuroischaemic ulcers
- Complications of surgically created or traumatic wound
I am not sure that this is a crisis with regard to diabetic foot ulcers since there is no ICD-10 code that is specific to diabetic foot ulcers. However, the focus of the comments to WPS has largely been over the debridement of DFUs. What really worries me is that the policy leaves out one of the biggest categories of ulcers which are “the wounds with no name.” Those are the chronic ulcers that are due to underlying medical conditions. They are not venous, not neuropathic and not neuroischaemic. They are just BAD. I have been warning that “the wounds with no name” (one of the largest wound categories), are going to end up getting “no care.” We don’t talk about them and we don’t do research on them – because they don’t fit nicely into a category. https://carolinefife.wpengine.com/2019/06/27/the-wounds-with-no-name-and-the-patients-who-will-get-no-care/
This is the real threat to our continued ability to provide wound management services and is another reason that real world data are desperately needed. The US Wound Registry could provide data on the prevalence rates of various wound types and their “natural history” and can even link the Medicare patients to the Medicare claims database. That is not likely to happen, and it’s a shame because all the MACs will eventually craft new LCDs on wound care, and each time coverage for a service or product is removed, the paragraph will include a statement about the “lack of evidence” to support it in the first place. This is one of the many things I don’t enjoy being right about. Policy makers do not understand what we SEE any more than they understand what we do, and the fault is ours, not theirs.
I will also add that these coverage policies are usually written in response to apparent abuse of codes. WPS clearly believes that these codes are being billed too frequently and they are moving to stop that practice. That Pandora’s box has to do with the way wound management services are reimbursed. We are effectively the coordinators for chronic diseases that result in wounds, and yet can’t be compensated for the scope and nature of the services we provide. Clinicians can bill for debridement, so they do. This is a much, much larger issue, and one that no one wants to talk about.