Effective Date: October 14, 2019

Purpose:
This policy provides guidelines for Ulcer Debridement and Ulcer Stages services when appropriately billed by professional providers

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Stage 1 Pressure Ulcer: Intact skin with non-blanchable erythema of a localized area, usually over a bony prominence.
• Stage 2 Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough.
• Stage 3 Pressure Ulcer: Full thickness skin loss down to subcutaneous tissue. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
• Stage 4 Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle.

Policy:
NJ Health shall consider for reimbursement CPT codes 11042-11047 (Debridement) when a Stage 1 or Stage 2 diagnosis is billed only if it is billed along with a Stage 3 or 4 Pressure Ulcer diagnosis or with a non-pressure chronic ulcer diagnosis.

According to the AMA CPT Manual, debridement of an ulcer that is limited to the skin (epidermis and/or dermis) should correctly be reported with active wound care management codes 97597 and 97698 depending on size, and not the surgical debridement CPT codes 11042-11047. Therefore, Horizon NJ Health shall not consider for reimbursement CPT codes 11042-11047 (Debridement) when billed with a Stage 1 or Stage 2 diagnosis only.

A stage 3 pressure ulcer involves full thickness skin loss down to subcutaneous tissue. Therefore, if a stage 3 pressure ulcer diagnosis is reported with debridement procedures involving muscle, fascia or bone (CPT codes 11043, 11044 or 11046, 11047), these procedures will be changed to a debridement procedure involving subcutaneous tissue (11042 or 11045), to correspond to the reported pressure ulcer stage diagnosis.

Example:

If CPT code 11043 (Debridement, muscle and/or fascia) is billed for a stage 3 pressure ulcer of the right hip (ICD-10 code L89.213), then the procedure and the diagnosis do not correspond to the same ulcer stage. Since the pressure ulcer was reported as stage 3, then the debridement procedure will be changed to 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) to correspond to the stage of the ulcer reported.

Procedure:
Horizon NJ Health shall reimburse CPT codes 11042-11047 (Debridement) when billed with a Stage 1 or Stage 2 pressure ulcer diagnosis only if it is billed along with a Stage 3 or Stage 4 pressure ulcer diagnosis or with a non-pressure chronic ulcer diagnosis.

Horizon NJ Health will reimburse CPT codes 11043, 11044 or 11046, 11047 (Debridement of muscle, fascia or bone) to either 11042 or 11045 (Debridement subcutaneous tissue [includes epidermis and dermis, if performed]) when billed with a pressure ulcer stage 3 diagnosis and a stage 4 pressure ulcer or a non-pressure chronic ulcer diagnosis. Reimbursement shall be at the applicable Horizon NJ Health fee schedule amount.

Horizon NJ Health shall deny CPT codes 11042-11047 (Debridement) when billed with a Stage 1 or Stage 2 pressure ulcer diagnosis if another pressure ulcer stage (3 or 4) or a non-pressure chronic ulcer diagnosis is not reported on the claim.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Local Coverage Article: Billing and Coding: Wound Care (A53001) cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53001&ver=21&LCDId=35125&Date=&DocID=L35125&bc=iAAAABABAAAA&

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services