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Medical Policy

Policy Num:      07.001.098
Policy Name:    Debridment
Policy ID:          [07.001.098]  [Ar / L / M+ / P-]  [0.00.00]

Last Review:      September 09, 2024
Next Review:      Policy Archived

Related Policies: None

Debridment

Summary

A wound is a disruption of the normal structure and function of the skin and skin architecture. An acute wound has normal wound physiology, and healing is anticipated to progress through the normal stages of wound healing, whereas a chronic wound is defined as one that is physiologically impaired. To ensure proper healing, the wound bed needs to be well vascularized, free of devitalized tissue, clear of infection, and moist. Wound dressings should eliminate dead space, control exudate, prevent bacterial overgrowth, ensure proper fluid balance, be cost-efficient, and be manageable for the patient and/or nursing staff. Wounds that demonstrate progressive healing as evidenced by granulation tissue and epithelialization can undergo closure or coverage. All wounds are colonized with microbes; however, not all wounds are infected.

  Debridement is the removal of infected, contaminated, damaged tissue, devitalized, necrotic tissue, and foreign material from a wound.

Objective

The objective of the review is to demonstrate that proper management of chronic wounds facilitates ordered restoration and regeneration of damaged tissue.

Policy Statements

Triple-S Salud considers payment for debridement when provided by the surgeon for the management of ulcers or wounds of the skin and underlying tissue to promote optimal wound healing or to prepare the area for adequate surgical intervention.

The requirements to consider a reasonable and medically necessary service are the following:

•  Safe and effective debridement methods more appropriate for the type of wound, according to standard medicine therapy

  •  That they take place in the appropriate setting: hospital, medical office, emergency room.

  • Services must be ordered and performed by qualified medical personnel with Wound Care Certification by the American Board or Wound Healing or surgical  specialty.

The coverage of Triple-S Salud for wound care (continuously) in a patient depends on the evidence documented in the patient's medical history that the wound is improving in response to the treatment being offered. It is not reasonable and medically necessary to follow a certain type of wound care if evidence of improvement of the wound cannot be documented.

 Evidence of improvement includes, but is not limited to, measurable changes in at least some of the following:

 1.  Drainage (color, quantity, consistency)

 2.  Discharge of secretion (color, quantity, consistency, odor, etc.)

 3.  Inflammation of the wound or injury

 4.  Edema of the anatomical area involved

 5.  Pain

 6.  Dimensions (wound diameter, depth, tunnels) - Cubic dimensions length, width and depth

 7.  Presence of granulation tissue Necrotic tissue / slough

Such evidence must be documented with each visit.

A wound that does not improve after 30 days requires a new approach that may include a re-evaluation by the doctor, in terms of possible identification of underlying infection, metabolic or nutritional disorders or vascular problems that inhibit wound healing. A new care plan or treatment method must be formulated.

Rarely, the goal of wound care planned in the outpatient setting can only be to prevent the progression of the wound. This is because the underlying weakness of the patient (associated with comorbidity factors) is not expected to improve.

Documentation requirements

The medical record maintained by the provider must clearly indicate the medical necessity of the service that is invoiced. The medical record must include the following information and be available for audits by Triple-S Salud upon request:

A surgical report or progress note is necessary for when the debridement service is performed. This note should describe the anatomical location treated, instruments used, anesthesia used (if necessary), type of tissue removed from the wound, depth, area of the wound and immediate postoperative care and follow-up instructions.

The following information must be available when the other services are provided:

 § Identification of the location of the wound, size, depth and stage of evolution. It must include a drawing or a photograph.

 § A description of the type (s) of affected tissues, the severity of tissue destruction, scouring or tunnels, necrosis, infection or evidence of reduced circulation.

 § A tissue pathology report obtained after the debridement procedure described by CPT code 11044. The documentation of the clinical history must show:

§ The condition of the wound is such that the treatment is expected to achieve a significant improvement over a reasonable and generally predictable period of time.

§ There is an expectation that the treatment will substantially affect tissue healing and its viability, reduce or control tissue infection, eliminate necrotic tissue or prepare tissue for surgical management.

§ The expected restoration potential of the patient must be significant in relation to the scope and duration of the required treatment. If wound closure is not a goal, then the expectation is to optimize recovery and establish an adequate non-specialized maintenance program.

 § The management of active rehabilitation for wounds and / or burns must be carried out by a physical or occupational therapist and must be carried out under a work plan. This service plan must describe the specific objectives, duration, frequency, modalities, estimate the anticipated endpoint and any other relevant factors as applicable. Departing from this plan must be documented.

Policy Guidelines

It is expected that these services will be performed as indicated by current medical literature and / or practice standards. When services are performed above the established parameters, they can be subject to revision.

The interval and the appropriate frequency of debridement depend on the individual clinical characteristics of the patients and the degree of the wound. Reducing the pressure and / or controlling the infection facilitates healing and reduces the need for repeated debridement services. The treatment plan for a patient that requires frequent debridement should be re-evaluated to ensure that pressure reduction and infection control have been adequately addressed.

Debridement services are not considered medically necessary when performed more often than once a week. The rationale and medical justification of the most frequent services must be clearly documented in the medical file, specifically if the debridement of chronic ulcers is more than eight of the total services of any of the codes contained in this policy (CPT codes 11000 to 97598).

Triple-S Salud does not consider for payment the following services as wound debridement:

The elimination of necrotic tissue for cleaning, scraping (other than for a scalpel or curette), application of chemical products, and / or wet-to-dry dressing.

    Wash the remains of bacteria or fungi from the lesions.

• The elimination of secretions and coagulation serum from the normal skin surrounding an ulcer.
• Cover small and superficial lesions with bandages.
• Removal of fibrinous material from the margin of the ulcer.
• Callus removal.
• Incision and drainage of abscess including paronychia, trimming or debridement of fungal nails, avulsion of nail plates, acne surgery, or destruction of  warts. Providers must report these procedures, when they represent covered, reasonable and necessary services, with appropriate CPT or HCPCS.
• The breakage of the skin under a callus is not recognized as ulcers and does not require debridement as long as there is no extension of the lesion to the subcutaneous tissue. Skin debridement (CPT codes 11000-11001)

 The CPT codes 11000 and 11001 describe the extensive elimination of eczematous areas or infected skin. Conditions that may require debridement of large amounts of skin are: infection of rapidly spreading necrotizing process (sometimes seen with aggressive streptococcal infections), severe eczema, bullous skin diseases, extensive skin trauma (including large areas eroded with soil) or earth), or autoimmune skin diseases (such as pemphigus).

Code CPT 11001 is not considered adequate for debridement of a localized amount of tissue that is normally associated with a circumscribed lesion. Examples of this are ulcers (grade 1, according to Wagner Classification), boils and localized infections of the skin.

Debridement of necrotizing soft tissue infections (CPT codes 11004-11008)

CPT codes 11004 to 11006 describe extensive skin debridement of subcutaneous tissue, muscle and fascia for the treatment of soft tissue necrotizing infections. In general, these debridement procedures are performed in high-risk patients. The code descriptor indicates the specific area that receives the treatment.

Code CPT 11008 describes the simultaneous removal of a mesh or prosthetic device.

Surgical debridement (CPT codes 11042-11047)

Surgical debridement is billed only if the material has been removed as part of the treatment of a wound to keep it clean and keep the site free of devitalized tissue including necrosis, eschar, slough, infected tissue, abnormal granulation tissue, etc. , to maintain viable tissue margins. Surgical excision includes beyond the point of visible necrotic tissue until viable tissue bleeding is found in some cases. The use of a sharp surgical instrument (eg scalpel) does not necessarily confirm the invoicing of surgical excisional debridement. The medical record should show that surgical excisional debridement has been performed. Debridements should be coded with either selective or non-selective codes (97597, 97598, or 97602).

Surgical debridement codes (11042-11047) describe the depth of the excised tissue and the treated surface of the wound. These codes represent extensive debridement often painful to the patient or may require complex surgical procedures that require the use of general anesthesia. Surgical debridement will be considered as not medically necessary when documentation indicates that the wound has no infection, necrosis or non-viable tissues and the wound has a pink to red color characteristic of granulation tissue.

The documentation to inform surgical debridement procedures should include:

The indications for the procedure.

•  The type of anesthesia when it is used.

•  The narrative report of the procedure that describes the injuries, as well like the details of the debridement procedure itself.

The selected CPT code should reflect the level of debrided tissue (eg, skin, subcutaneous tissue, muscle and / or bone). They are not related to the range, depth or degree of the ulcer or wound. For example, the code CPT 11042 defines as "debridement, subcutaneous tissue" that should be used if only the necrotic subcutaneous tissue is debrided, even though the ulcer or wound may extend to the bone. This code should not be invoiced if only fibrin is removed. It is not expected that a particular wound will be debrided repeatedly, since the skin and subcutaneous tissue do not grow back quickly. The process can take a week.

The following components should be analyzed and documented for the purpose of evaluating the progress of the ulcer:

 •  Type of ulcer, etiology (eg pressure).

•  Location: It must be specific and, if necessary, close anatomical margins should be indicated.

•  Description of the wrapped fabric: total thickness, partial thickness; ulcer stage.

•  Size (length, width and depth).

•  Presence, tunnel size.

•  Appearance of the ulcer / type of tissue (Example color of the base of the ulcer, granulation or absence of granulation, epithelialization, esfacelo,   

   eschar).

•  Presence of exudate - Quantity, color, smell, type or consistency.

•  Appearance of the margins of the ulcer.

•  Appearance or condition of the adjacent tissue of the ulcer.

Handling wound care and / or burns

Debridement is indicated when necrotic tissue is present in an open wound. Debridement may also be indicated in cases of abnormal wound healing. Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue.

This procedure includes evaluation of the wound or burn, debridement, application of ointments, creams, sealants, other wound coverings and instructions for ongoing care. It must be billed no more than once a day, regardless of the number of injuries.

In the case of burn care, the codes to be used are 16020, 16025 and 16030.

Selective debridement (97597 and 97598)

The CPT codes 97597 and 97598 are used for the removal of specific and specific areas of devitalized or necrotic tissue from a wound along the margin of viable tissue. Occasional bleeding and pain may occur. The routine application of a topical or local anesthetic does not elevate the active management of wound care to one of surgical debridement. Selective debridement includes:

1.  The selective elimination of necrotic tissue by cutting dissection such as scissors, scalpel and forceps.

2. The selective elimination of necrotic tissue by high pressure water jet.

Benefit Application

BlueCard/National Account Issues

N/A

Background

N/A

Regulatory Status

N/A

Rationale

Wounds that have devitalized tissue, contamination, or residual suture material require debridement prior to further wound management. Acute traumatic wounds may have irregular devitalized edges or foreign material within the wound, and surgical wounds that have dehisced may have an infected exudate, bowel contamination, or necrotic muscle or fascia. These materials impede the body's attempt to heal by stimulating the production of abnormal metalloproteases and consuming the local resources necessary for healing.

Characteristics of chronic wounds that prevent an adequate cellular response to wound-healing stimuli include accumulation of devitalized tissue, decreased angiogenesis, hyperkeratotic tissue, exudate, and biofilm formation (ie, bacterial overgrowth on the surface of the wound). These wounds often require planned serial debridement to restore an optimal wound healing environment.

Population Reference No. 1 

Individuals with open wound.  Interventions of interes are proper wound healing. Comparator of interest is inadecuate wound healing. Relevant outcome includes: Quality of life, Morbid events, Hospitalizations.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1.    Ayello, E., & Cuddigan, J. (2004). Debridement: Controlling the necrotic/cellular burden. Advances in Skin & Wound Care, 17:66-78.

2.    Black, J., Baharestani, M., Cuddigan, J., Dorner, B., Edsberg, L., Langemo, D., & et al. (2007). National pressure ulcer advisory panel’s updated pressure ulcer staging system. Dermatolgy Nursing. 19(4): 343-349.

3.    Choucair, M. M., Fivenson, D. P. (2001). Leg ulcer diagnosis and management. Retrieved March 19, 2002 from http://homeconsult.com/das/article/body/1/jorg=journal&source=MI&sp=12040563&sid This reference provided information surrounding appropriate diagnoses criteria.

4.   CPT Assistant – June 2005 & October 2007

5.   CPT Changes: An Insider’s View – 2005, & 2008, 2011

6.   Debridement. (2004). Body1, Inc. Retrieved October 6, 2008 from http://www.wounds1.com/care/procedure20.cfm/19

7.   Deery, H. G., & Sangererozan, J. A. (2001). Saving the diabetic foot with special reference to the patient with chronic renal failure. Retrieved March 19, 2002 from http://home.mdconsult.com/das/article/body/1/jorg=journal&source=MI&sp=11974766&sid This reference provided definitions and indications for wound management.

8.   Fife, C. (2008). The debridement predicament. Retrieved October 6, 2008 from: http://www.intellicure.com/News/2008_01-02_Pulse/debridement _predicament.htm

9.   Lewis, R., Whiting, P., ter Riet, G., O’Meara S., & Glanville, J. (2001). A rapid and systemic review of the clinical effectiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary intention. Retrieved March 19, 2002 from http://home.mdconsult.com/das/citation/body/jorg=journal&source=MI&sp=11892394&sid This reference provided expectations of treatments for wounds.

10.   Paquette, D., & Fatanga, V. (2002). Leg ulcers. Retrieved March 19, 2002 from http://home.mdconsult.com/das/article/body/1/jorg=journal&source=&sp=12074980&sid This reference provided descriptions and treatments for leg wounds.

11.   Salcido, R., & Popescu, A. (2006). Pressure ulcers and wound care. Retrieved October 1, 2008 from: http://www.emedicine.com/pmr/TOPIC179.HTM

12.   Schaum, K. (2006). Newly funded selective and non-selective debridement CPT codes: Impact on hospital-owned outpatient wound care departments. Healthpoint, Inc. Retrieved October 1, 2008 from: http://www.woundsresearch.com/docs/Healthpoint_August.pdf

13. Stillman, R. (2008). Diabetic ulcers. Retrieved October 2, 2008 from: http://www.emedicine.com/med/TOPIC551.HTM

14. Suzuki, K. & Cowan, L. (2009). Current concepts in wound debridement. Podiatry Today, 22(7) July 1.

15.Tatsioni, A., Balk, E., O’Donnell, T., Lau, J. (2007). Usual care in the management of chronic wounds: A review of the recent literature. Journal of the American College of Surgeons, 205(4).

16. Ulcer. (2008). New World Encyclopedia. Retrieved October 2, 2008 from http://www.newworldencyclopedia.org/entry/Ulcer?oldid=683900

17. Valencia, I., Falabella, A., Kirsner, R. S., & Eaglstein, W. E. (2001). Chronic venous insufficiency and venous leg ulceration. Retrieved March 19, 2002 from http:/home.mdconsult.com/das/article/body/1/jorg=journal&source=MI&sp=11546251&sid This reference defined and discussed debridement and other treatment modalities.

18. Debridement. (2004). Body1, Inc. Retrieved October 6, 2008 from http://www.wounds1.com/care/procedure20.cfm/19

19. Deery, H. G., & Sangererozan, J. A. (2001). Saving the diabetic foot with special reference to the patient with chronic renal failure. Retrieved March 19, 2002 from http://home.mdconsult.com/das/article/body/1/jorg=journal&source=MI&sp=11974766&sid This reference provided definitions and indications for wound management.

20. Fife, C. (2008). The debridement predicament. Retrieved October 6, 2008 from: http://www.intellicure.com/News/2008_01-02_Pulse/debridement _predicament.htm

21. Lewis, R., Whiting, P., ter Riet, G., O’Meara S., & Glanville, J. (2001). A rapid and systemic review of the clinical effectiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary intention. Retrieved March 19, 2002 from http://home.mdconsult.com/das/citation/body/jorg=journal&source=MI&sp=11892394&sid This reference provided expectations of treatments for wounds.

22. Paquette, D., & Fatanga, V. (2002). Leg ulcers. Retrieved March 19, 2002 from http://home.mdconsult.com/das/article/body/1/jorg=journal&source=&sp=12074980&sid This reference provided descriptions and treatments for leg wounds.

23. Salcido, R., & Popescu, A. (2006). Pressure ulcers and wound care. Retrieved October 1, 2008 from: http://www.emedicine.com/pmr/TOPIC179.HTM

24. Schaum, K. (2006). Newly funded selective and non-selective debridement CPT codes: Impact on hospital-owned outpatient wound care departments. Healthpoint, Inc. Retrieved October 1, 2008 from: http://www.woundsresearch.com/docs/Healthpoint_August.pdf

25. Stillman, R. (2008). Diabetic ulcers. Retrieved October 2, 2008 from: http://www.emedicine.com/med/TOPIC551.HTM

26. Suzuki, K. & Cowan, L. (2009). Current concepts in wound debridement. Podiatry Today, 22(7) July 1.

27. Tatsioni, A., Balk, E., O’Donnell, T., Lau, J. (2007). Usual care in the management of chronic wounds: A review of the recent literature. Journal of the American College of Surgeons, 205(4).

28. Ulcer. (2008). New World Encyclopedia. Retrieved October 2, 2008 from http://www.newworldencyclopedia.org/entry/Ulcer?oldid=683900

29. Valencia, I., Falabella, A., Kirsner, R. S., & Eaglstein, W. E. (2001). Chronic venous insufficiency and venous leg ulceration. Retrieved March 19, 2002 from http:/home.mdconsult.com/das/article/body/1/jorg=journal&source=MI&sp=11546251&sid This reference defined and discussed debridement and other treatment modalities.

Codes