The Department of Health and Human Services (“DHHS”) Office of Inspector General (“OIG”) just published a report detailing its investigation into Medicare payments for surgical debridement services (CPT codes 11040-11044): Medicare Payments for Surgical Debridement Services in 2004. The findings of the investigation and the recommendations in this report should be carefully considered by ACFAS members as focused reviews of these services are likely to increase as a result.

The OIG conducted a medical record review of surgical debridement services in 2004 to determine the extent these services met Medicare program requirements. It concluded that sixty-four percent of the surgical debridement services reviewed did not meet Medicare program requirements. Thirty-nine percent of surgical debridement services were billed with a code or modifier that did not accurately reflect the service provided. Almost half of these miscoded services were not surgical debridement at all but actually routine foot care which should not have been paid by Medicare. Twenty-percent of the miscoded services involved the removal of a benign hyperkeratotic lesion that had been billed as surgical debridement. Several claims included a -59 modifier when it was not needed. Another twenty percent of the miscoded services were billed with a code that did not accurately reflect the level of tissue, muscle or bone removed during the debridement (the medical record indicated that tissue was debrided to, but not including muscle, but the physician billed 11043: Debridement of skin, subcutaneous tissue, and muscle).

Twenty-nine percent of services reviewed had no documentation or insufficient documentation to determine whether the services were medically necessary or were coded accurately. For example, one physician failed to submit any documentation at all and another record indicated that the physician changed wound dressings but did not provide enough information to determine whether he actually debrided the wound.

One percent of all of the surgical debridement services reviewed were not medically necessary. The records indicated wounds did not need debridement. For example, one record documented that an ulcer required dressing changes but not surgical debridement and another record contained a description of a wound with healthy pink tissue and no evidence of infection.

Of all the surgical debridement claims submitted to Medicare in 2005, sixty-six percent were performed by podiatrists. What does this mean for ACFAS members? Be prepared! As a result of this investigation, carriers are likely to conduct focused reviews of surgical debridement services, in particular those submitted by podiatrists. In fact, some carriers may have already begun conducting pre-pay audits for surgical debridement services. Become familiar with your carriers’ policy for payment of these services. Carefully review your claims for these services before submitting them to your carrier and always be sure that there is sufficient documentation in the medical record to support the code.