Coder's Corner

by R. Lawrence Reed III, MD, FACS, FCCM & Thomas Esposito, MD, MPH

Here are a scenario and questions for the next Coders’ Corner from Dr. David Skarupa of the University of Florida College of Medicine - Jacksonville. This is the second part of a 3 case series:

2^nd case:  necrotizing acute soft tissue infection perineum, groin, lower abdominal wall and thigh

Procedures:

• Excisional debridement skin, subcutaneous tissue, fascia and muscle total wound 30x35

Questions:

• How to code the soft tissue debridement that involves perineum, abdominal wall, groin and lower extremity?
• Is it best to code under perineum debridement?
• Is it best to code under abdominal wall debridement?

Is it best to separate wound size and code separately?

Response from Dr. Esposito:

Procedures:

• 11006 (13.10 WRVU)- this covers external genitalia, abdominal wall & perineum. This might be the best option. We would not add a 52 modifier for reduced services just because external genitalia was not debrided. However this does not cover the thigh debridement.
• 11005 (14.24 WRVU)- this is for abdominal wall only.
• 11043 (2.70 WRVU) for 1^st 20 sq. cm. & 11046 (1.03 WRVU) for each additional 20 sq. cm.
• Another option is to bill for abdominal wall with 11005 & then 11043 & 11046 for thigh & perineum separately. Wound size is needed for these codes. Additionally, they will need 59 modifiers since they bundle with 11005.

 Response from Dr. Reed:

Dr. Esposito and his assistant have correctly addressed the key points of this exercise and have done so – as they have described – “very succinctly”.  I have provided information  and comments below to clarify and provide a more detailed rationale for the coding issues.

Comment: There is a great deal of confusion regarding these codes which are, unfortunately, a common procedural issue in the field of Emergency General Surgery.  At first glance, it would appear simple to use 11004 for the external genitalia and the perineum and combine it with 11005 for the abdominal wall debridement when necessary.   However, as Dr. Esposito points out, the genitalia were not debrided, so a 52 modifier for reduced services would be appropriate, and it’s never clearly laid out how reduced the payment may become.  It makes no sense to use 11006 as the numbers do not add up: why should debridement the external genitalia, perineum, and abdominal (11006) wall pay less than the abdominal wall debridement by itself (11005)?  If you combined 11004 & 11005, the best the surgeon would receive would be $902.42, but that would likely be diminished with the 52 modifier on 11004.  Also, and importantly, the CCI edits indicate that 11004 & 11005 cannot be billed together because of a “Misuse of column two code with column one code” and no modifier is allowed.  Hence the best (and likely only) solution is to carefully measure and document the total surface area debrided and bill 11043 with the appropriate multiples of 11046.