Guidance on Wound Debridement, Wound Biopsy, and CPT Coding for Compliant Care

Posted July 2022 and Updated Sept 2023– Histologics LLC

Guidance Provided by:
Jeffrey D Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Certified Professional Coder
Certified Professional Medical Auditor

Staff Liaison to the AMA CPT Editorial Panel
Advisor, American Podiatric Medical Association Coding Committee
Past Chairman of the Board of Directors, American Society of Podiatric Surgeons
Past Director, American Professional Wound Care Association
Editorial Advisory Board, WOUNDS
Former Medical Director, Center for Wound Healing and Hyperbaric Medicine at Crozer-Chester
Medical Center
Adjunct Clinical Professor, Temple University School of Podiatric Medicine
Fellow, American Academy of Podiatric Practice

What are the wound ulcer debridement CPT® code options to the clinician or facility performing the various levels of debridement? Which forms of wound hygiene or debridement are reimbursed? What is the importance of the size of the ulcer/wound during a debridement session?

CPT® 97602 - Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion) including topical application(s), wound assessment, and instruction(s) for ongoing care, per session.

Reimbursement:
This CPT code may not be submitted by providers. This can only be submitted by a facility. CPT 97602 is not payable to providers. The situation where this CPT code may be used:
Doctor sees a patient in a facility (like a HOPD wound center) and does not perform any procedure to the wound. Doctor only submits an evaluation and management service and the doctor orders non-selective debridement be performed by facility staff. Facility staff perform the non-selective debridement and the facility submits CPT 97602. If the doctor debrides, biopsies, grafts, etc (any procedure) the wound, the facility may not submit CPT 97602 for that wound.

Dermal “Selective” Debridement by a Clinical Provider
CPT® 97597 – Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session; total wound(s) surface area; first 20 sq cm or less.
*The submission of CPT 97597 is not dependent on which instrument is used. If you perform the service described by CPT 97597, you can submit CPT 97597, regardless of what instrument was used to accomplish the procedure.

Deeper Debridement
CPT® 11042 – Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less
CPT 11043® – Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less.
CPT 11044® - Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

The four debridement base CPT codes listed above each only account for the first 20 sq cm of tissue removed. If more than 20 sq cm of tissue is removed at a particular depth, an add-on CPT code should be listed in addition to the base CPT code. For each of the four depths of debridement, the add-on CPT codes are2:

CPT® 97598 - Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session; total wound(s) surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
CPT® 11045 - Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
CPT® 11046 - Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
CPT® 11047 - Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

CPT 97598, 11045, 11046, and 11047 are all considered “add-on” CPT codes and, as such, no 59, 51, or X[ESPU] Modifier is needed when submitting these CPT codes in addition to their corresponding base code.

If more than 20 sq cm of tissue is removed at a particular depth, one unit of the base code should be listed and, on a second line of the claim form, the appropriate add-on code should also be listed with the number of units of that add-on code representing how many increments of 20 sq cm of tissue were removed at that depth beyond the first 20 sq cm.

For example, if 36 sq cm of subcutaneous tissue is debrided, the appropriate CPT coding is: CPT 11042 – 1 unit
CPT 11045 – 1 unit

If 86 sq cm of subcutaneous tissue is debrided, the appropriate CPT coding is: CPT 11042 – 1 unit
CPT 11045 – 4 units

If multiple ulcers are debrided at the same depth, the total amount of tissue removed from all of them should be totaled to determine the appropriate CPT code(s). If multiple ulcers are debrided to different depths, then the different CPT codes representing the different depths of debridement must be submitted.

Page 95 of the 2023 CPT Professional Edition book states:
In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths.

If 4 sq cm of subcutaneous tissue is debrided from one ulcer and 6 sq cm of subcutaneous tissue is debrided from another ulcer, the total sq cm of subcutaneous tissue removed is 10 sq cm and one unit of CPT 11042 should be submitted. Because multiple ulcers were debrided to the same depth, the total amount of tissue removed from all of them is totaled to determine the appropriate CPT code.

If 4 sq cm of subcutaneous tissue is debrided from one ulcer, and 1 sq cm of subcutaneous tissue is debrided from another ulcer, ulcer and 5 sq cm of subcutaneous tissue is debrided from another ulcer, the total sq cm of subcutaneous tissue removed is 10 sq cm and one unit of CPT 11042 should be submitted. Because multiple ulcers were debrided to the same depth, the total amount of tissue removed from all of them is totaled to determine the appropriate CPT code.

If 4 sq cm of subcutaneous tissue is debrided from one ulcer and 6 sq cm of muscle is debrided from another ulcer, one unit of CPT 11042 and one unit of CPT 11043 should be submitted. Because multiple ulcers were debrided to different depths, the appropriate, different CPT codes representing the different depths of debridement are submitted.

Reimbursement:

All of these CPT codes appear on the Physician Fee Schedules of all seven Part B Medicare Administrative Contractors. 
*Facility examples include inpatient hospital, outpatient hospital, and skilled nursing facility
**Non – Facility example is private office
***Falls under the Inpatient Prospective Payment System Severity Diagnosis Related Group (MS-DRG)

2023 Medicare (MC) national average payments for these services are outlined in the chart below:

Performing Tangential Biopsy and Ulcer Debridement at the Same Session
Direction regarding coding for multiple procedures at the same encounter is provided by the National Correct Coding Initiative (NCCI)4. Chapter I, Section A of the NCCI Policy Manual5 states, “a physician shall not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services.”

The NCCI publishes procedure – to - procedure (PTP) edits for certain CPT code combinations. These edits are usually based upon the standards of medical / surgical practice5. When one service is considered to be an integral component of another service, the CPT codes that represent the two services are paired by a NCCI PTP edit. In general, when a pair of services is provided at the same encounter whose CPT codes are paired by a NCCI PTP edit, both CPT codes should not be reported unless it is clinically appropriate to use an NCCI PTP-associated modifier.

The NCCI PTP edits pair CPT 97597/975988 and 11042-11047 with CPT 11102/11103, meaning any of these code combinations should not be submitted together unless it is clinically appropriate to use an NCCI PTP-associated modifier. When tangential biopsy and ulcer debridement are performed at the same site, it is not appropriate to use an NCCI PTP-associated modifier. The NCCI PTP edits that pair CPT 97597/975988 and 11042-11047 with CPT 11102/11103 place CPT 97597/975988 and 11042-11047
in column 2 with CPT 11102/11103 in column 1. This means when both of these procedures are performed at the same site only the tangential biopsy CPT codes (CPT 11102/11103) should be submitted and the ulcer debridement CPT codes (CPT 97597/975988 and 11042-11047) should not be submitted.

If a tangential biopsy is performed at one site and ulcer debridement is performed at another site, CPT coding may be submitted for both procedures because it is appropriate to use an NCCI PTP-associated modifier when these procedures are performed at different sites.

If a debridement and tangential biopsy are performed at one site and only ulcer debridement is performed at another site, CPT coding may be submitted representing the work performed at both sites because it is appropriate to use an NCCI PTP-associated modifier when the work is performed at different sites. In this situation only the tangential biopsy CPT code may be submitted for the work performed at the first site and a debridement CPT code may be submitted for the work performed at the second site.

What about cases where Non-Selective Debridement 97602 is performed but a biopsy or skin substitute/graft placement is performed as well?

An example where this is relevant:
Doctor sees a patient in a facility (like a HOPD wound center) and does not perform any procedure to the wound. Doctor only submits an evaluation and management service and the doctor orders non-selective debridement be performed by facility staff. Facility staff perform the non-selective debridement, and the facility submits CPT 97602. If the doctor debrides, biopsies, grafts, etc. (any procedure) the wound, the facility may not submit CPT 97602 for that wound.

Non-selective debridement or "wound hygiene" performed before or after a wound biopsy should not affect the CPT coding for the biopsy procedure performed by a certified professional in a clinical setting.

Guidance Provided by: 
Jeffrey D Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Certified Professional Coder
Certified Professional Medical Auditor
Diplomate, American Board of Foot & Ankle Surgery

Staff Liaison to the AMA CPT Editorial Panel
Advisor, American Podiatric Medical Association Health Policy and Practice Deps
Past Chairman of the Board of Directors, American Society of Podiatric Surgeons
Past Director, American Professional Wound Care Association
Editorial Advisory Board, WOUNDS
Former Medical Director, Center for Wound Healing and Hyperbaric Medicine at Crozer-Chester
Medical Center
Adjunct Clinical Professor, Temple University School of Podiatric Medicine
Fellow, American Academy of Podiatric Practice

What is tangential biopsy and how do I code this procedure in a compliant manner?

Tangential Biopsy
Page 81 of the 2023 CPT Professional Edition book states:
“Tangential biopsy (eg, shave, scoop, saucerize, curette) is performed with a sharp blade, such as a flexible biopsy blade, obliquely oriented scalpel or curette to remove a sample of epidermal tissue with or without portions of underlying dermis.  The intent of a tangential biopsy (11102, 11103) is to obtain a tissue sample from a lesion for the purpose of diagnostic pathologic examination.  Biopsy of lesions by tangential technique (11102, 11103) is not considered an excision. Tangential biopsy technique may be represented by a superficial sample and does not involve the full thickness of the dermis, which could result in portions of the lesion remaining in the deeper layers of the dermis.”

When a tangential biopsy, as defined by CPT above, is performed, the appropriate CPT code is CPT 11102.
CPT 11102 - Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion.
If more than one tangential biopsy is performed, CPT 11102 must be reported to represent the first biopsy and CPT 11103 must also be reported to represent each additional tangential biopsy performed.
CPT 11103 is considered an “add-on” CPT code and, as such, no 59, 51, or X[ESPU] Modifier is needed when submitting CPT 11103 with CPT 11102. When multiple tangential biopsies are performed, one unit of CPT 11102 should be listed and, on a second line of the claim form, CPT 11103 should also be listed
with the number of units of CPT 11103 representing the number of tangential biopsies performed beyond the first.

When two different tangential biopsies are performed, the appropriate CPT coding is:
CPT 11102 – 1 unit
CPT 11103 – 1 unit
When four different tangential biopsies are performed, the appropriate CPT coding is:
CPT 11102 – 1 unit
CPT 11103 – 3 unit

Are non-contact wound fluorescence imaging and wound biopsy paired, and can they be coded and reimbursed for the same wound that is managed?

Noncontact real-time fluorescence wound imaging, for bacterial presence, location, and load, per session; first anatomic site (e.g., lower extremity) (CPT 0598T) is not bundled with biopsy CPT codes.  Therefore, the imaging performed, and biopsy may be performed for the same wound and both submitted.  If the provider also orders non-selective debridement after performing the imaging and biopsy, that does not change the coding.

What does the Physician Fee Schedules list as national average payments in 2023 for these services?

*Facility examples include inpatient hospital, outpatient hospital, and skilled nursing facility
**Non – Facility example is private office
***Falls under the Inpatient Prospective Payment System Severity Diagnosis Related Group (MS-DRG)

Surgical Debridement of Wound Bed

The appropriate CPT® codes to use when surgical preparation of a wound bed is performed in anticipation of applying any form of NPWT are CPT 15002-15005.  The 2023 CPT Professional statess, “codes 15002-15005 for skin replacement surgery describe the initial services related to preparing a clean and viable wound surface for placement of an autograft, flap, skin substitute graft or for negative pressure wound therapy.”  In the same book section, CPT goes on to describe that these codes should be used when debridement of the wound bed is performed in anticipation of a flap, graft application, skin substitute application, or the institution of NPWT.   

CPT 15002 – Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children

CPT 15003 - Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)  (Add-on code to be used with CPT 15002)

CPT 15004 - Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children

CPT 15005 - Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)  (Add-on code to be used with CPT 15004)

2023 Medicare national averages are shared below:

Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2022 by the American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association (AMA). 

Dr. Lehrman states: As a Board -Certified Foot and Ankle Surgeon, Board Certified Professional Coder and Board Certified Professional Medical Auditor, these recommendations are made with a reasonable degree of certainty.