Skin Deep. Agenda. Burns Wounds Debridement Evaluation and Management Services. Presented by: Mike Strong, SFM The Work Comp Experts.

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1 Presented by: Mike Strong, SFM The Work Comp Experts Agenda Wounds Debridement Evaluation and Management Services 2 1

2 Types of First Degree Second Degree Third Degree Rule of 9 Adults Infants Burn Coding CPT CPT Types of First Degree Redness, Swelling, Pain, Dry/Peeling Skin Surface / Local Second Degree Deeper than top layer, blistering, extremely red and sore Partial (Local) or Full Thickness (Possible need for skin grafting) Third Degree Full-thickness. May include bloodstream, major organs, bones. Can be deadly Surgery, physical therapy, antibiotics, rehab, other extensive care 4 2

3 Rules of 9 Body Location Adult Child Head & Neck 9% 18% Chest 18% 18% Back 18% 18% Arms (Each) 9% 9% Legs (Each) 18% ~14% Genitalia 1% 1% Total 100% 100% 5 6 3

4 Why is this important? Provides the background needed to determine how the diagnosis, treatment, and severity of burn can affect the coding How does this affect me as a coder? Codes vary depending on the depth of the skin burn, the percentage of total body surface area (TBSA) of the burn or amount of square centimeters (sq. cm.), grafts and flaps, and/or use of debridement. 7 Local First and Partial Thickness Second degree burns CPT Burned surface only Includes the application of materials, such as dressings Documentation must include the percentage of body surface involved and depth of burn. 8 4

5 Example 1: A 42-year-old tourist to Daytona Beach fell asleep in the sun. Upon waking, the tourist noticed red skin on the legs and feet with pain upon movement and contact. Some swelling is noted in the joints. The individual presents to a local urgent care center and receives a diagnosis of first degree sun burn. The provider applies some aloe vera cream and wrapped some gauze around the knees. The patient was advised to take some over-the-counter pain killers and apply the cream vigorously for 2 days. Patient was advised that symptoms should resolve within a week. What is the code? 9 Answer: CPT Initial treatment for the first degree burn Follow-up is uncommon so future care not needed Only local treatment required 10 5

6 Example 2: A 30-year-old chef got burned at work when he accidentally bumped into a cook carrying boiling hot water. Some of the water spilled and burned the chef s right arm. The burns were second degree partial thickness. Approximately 7% of the arm has second degrees partial thickness burns. The patient presents to the emergency room, where the ER physician performs some debridement to the burns on the hands with the entire arm treated with aloe vera cream. The entire arm is wrapped in gauze. How is this initial treatment coded? 11 Answer: CPT % second degree partial thickness burn to the right arm Initial treatment: dressings & debridement Follow-up: He follows-up with his primary care physician in 10 days. Partial thickness second degree burns remain on the hands and part of the forearm (~2%). Treatment include dressings with aloe vera cream. This would be coded as CPT

7 Guidelines are not used for debridement of burns are not used for debridement/treatment of burns Only use for debridement of burns Skin grafting for full-thickness or deep partial thickness second degree burns are reported separately with do not require skin grafting (CPT Assistant Oct. 2012) NCCI edits bundle into the grafting codes NCCI edits do not bundle with skin graft codes 13 What about full-thickness burns for skin grafting? First report skin preparation codes Second report appropriate code for the placement of the autograft, flap, or skin substitute graft. 14 7

8 Requirements for Code Selection for Skin Replacement Surgery ( ) Type of Procedure* Surgical preparation, Autografts, Skin substitute grafts, flaps Location Trunk, arms, legs Face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits Size/Area Size in sq. cm. for adults or % infants and children 15 Type of Procedure may have additional requirements Surgical Preparation Location Size of the defect Sum size of all wounds from the anatomic sites that are grouped into the same code descriptor 16 8

9 Type of Procedure may have additional requirements Autografts Include harvest and/or application of autologous skin graft Includes removal of current graft and/or simple cleansing of the wound Repair of donor site reported separately Do not report CPT Code from Code based on type of autograft, location, and size of the defect Sum size of all wounds from the anatomic sites that are grouped into the same code descriptor 17 Type of Procedure may have additional requirements Skin substitute grafts Include non-autologous human skin, non-human skin, and biological products that form scaffolding for skin growth Not for non-graft wound dressings or injected skin substitutes Do not report CPT Code from Code based on location and size of the defect Sum size of all wounds from the anatomic sites that are grouped into the same code descriptor The supply of skin substitute graft(s) should be reported separately in conjunction with (CPT 2016) 18 9

10 Type of Procedure may have additional requirements Flaps Regions refer to recipient area not the donor for transfer or final site Regions refer to donor area when a tube is formed for later transfer or delay of flap occurs prior to the transfer. Codes are described by donor site of the muscle, myocutaneous, or fasciocutaneous flap. (CPT 2016) Extensive immobilization not included in Example 3: A 50-year-old female chemist received 3 rd degree chemical burns in the lab to her hands, face, and arms. The provider performs surgical preparation for 50 sq. cm. wounds to the face and hands with a surgical preparation for the 125 sq. cm. wounds on the arms. The provider applies a xenograft to the surgically prepared defects. 175 sq. cm. of Mediskin was required. How is this coded? 20 10

11 Answer: x x x 1 Q4135 x , 15275, and are for the 50 sq. cm to the face & hands 15002, 15003, 15273, and are for the 125 sq. cm. arms Q4135 x 175 sq. cm. Mediskin 21 Wounds Active Wound Care Management (CPT ) CPT are for wounds other than burns CPT are for debridement of the skin (epidermis and dermis) CPT is a Status B code on the Medicare Relative Value Unit Table CPT can be used for Negative Pressure Wound Therapy (CPT ) June 2005 CPT Assistant state these codes are for non-physicians (Nurse Practitioners, Physician Assistants, Wound Care Nurses, Physical Therapists, Enterostomal Therapy Nurses). Physicians should use the surgical debridement codes

12 Surgical Preparation (CPT ) Intended for wounds that are healing by primary intention. Negative Wound Therapy Do not use if wounds healed by secondary intention CPT CPT Wounds Selective Debridement (CPT ) Based on total surface area of wound size 23 Wounds Negative Pressure Wound Therapy (CPT ) Based on total surface area of wound size Based on use of durable medical equipment (DME) or disposable, non-durable medical equipment DME CPT Disposable, non-durable medical equipment CPT Do not report with Dressings are not reported separately and are included in the services performed 24 12

13 Wounds Low Frequency Ultrasound (LFU) (CPT 97610) Used for various chronic wounds Used to help restore adequate blood flow Stimulates cells within and below the wound Not the same as selective debridement (CPT ) Not the same as other PT services for ultrasound, infrared, or low level laser (CPT 97035, 97026, or S8948) Sharp debridement, negative pressure wound therapy, and skin substitutes may be performed before or after LFU and is reported separately 25 Debridement Surgical Debridement (CPT ) All wounds of the same depth treated by surgical debridement are summed together and reported as one code Surgical debridement of wounds at different levels/depths are reported separately with modifier 59. Reported based on the deepest level of a wound debrided even if multiple levels of the same wound are debrided Example single wound debrided at the subcutaneous level and at the bone would be reported based on the debridement of the bone Cannot be reported with Active Wound Care Management (CPT ) for the same wound 26 13

14 Debridement Surgical Debridement (CPT ) Based on surface area and depth: Wound surface biofilm/epidermis/dermis Subcutaneous tissue Muscle or fascia Bone Wound surface for the epidermis and dermis are coded with CPT Measurement of the wound size is determined after the debridement procedure occurred 27 Other debridement services: Debridement Dermabrasions (CPT ) Nail debridement (CPT ) (CPT ) Pressure ulcers (CPT ) CPT requires excision If no excision, use CPT or

15 Evaluation and Management Services 29 E/M Distribution for New Patient Office Visits CMS Utilization Files

16 E/M Distribution for Est. Patient Office Visits CMS Utilization Files E/M Distribution for Initial Hospital Visits CMS Utilization Files

17 E/M Distribution for Subsequent Hospital Visits CMS Utilization Files E/M Distribution CMS Data most recent as of December 31, 2015 Office Visits and most prevalent Hospital Visits and most prevalent Deviation from the prevailing norm increases risk of audits and allegations of upcoding, fraud, abuse, overutilization, medically unnecessary services 34 17

18 Established Problems Questions to Consider What is the benefit of obtaining a past medical, family, or social history? Will an extended or comprehensive examination change the treatment plan? Is it likely that an extended or comprehensive examination will produce any unanticipated changes in the patient s condition? 35 Example: Questions to Consider A 25-year-old female chemistry student returns to the clinic for follow-up of superficial, partial thickness, second degree chemical burns. Patient was last seen in this clinic a week earlier for the initial treatment for these burns. The patient s wounds are continuing to heal as expected and is returning for an examination of the scar tissue. A 10-point ROS was performed today with a review of the patient s past medical, family, and social history. Exam of the blood flow, pulses, and nerves were normal. Minimal scarring present. Patient is A&Ox3 and is in no apparent distress. Service is coded as a

19 Summary Type of wound (burns vs. non-burns) Depth of wound (epidermis, dermis, subcutaneous, muscle, fascia, bone) Type of procedure (surgical, selective, non-selective, negative pressure) Type of skin replacement (autografts vs. skin substitute grafts) 37 References Centers for Medicare and Medicaid Services (CMS) Utilization Files EncoderPro 1997 Documentation Guidelines American Burn Association CPT Manual 38 19

20 References AMA CPT Assistants: June 2005 May 2011 March 2012 January 2012 October 2012 June 2014 November Questions?? Picture obtained from WebMD 40 20

21 Thank You! Michael Strong, MSHCA, MBA, CPC, CEMC Cell: (952)

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