Wound care coding

[air bud]

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Ok, I hate to try and make this forum a place of useful discussion...but here goes. Let's talk about wound care coding. Specifically related to global periods.
Patient has a TMA. It dehisces. They follow up with you at wound care.

Is that still an ulcer or is a dehiscence?

Is debridement billable?

Does it matter if excisional vs non excisional?

If you need to culture, get images, vascular testing related to it not healing....is that an EM?

If the Answer to all this is no, all part of global...should you see these in wound center or have someone else see it since will be billable by them?

 

[MicroPod]

I think if they develop an infection or other issue at a postop visit, you should be able to bill e/m since its a new problem you are putting as a diagnosis. Not sure about ulcer vs dehiscence question.

 

[Adam Smasher]

Everytime I do an amp, instead of saying that I closed the wound, I'll document that "The wound edges were reapproximated with 2-0 prolene [or whatever] retention sutures to allow for definitive closure at a future date if necessary."

This way any debridement or incision revision during the postoperative global are technically part of a planned staged approach and can be billed with a -58 modifier. By the way, this is on paper the vascular surgery approach to amputations, just cut it off and leave a bloody stump to let it heal in secondarily, so don't tell me it's not the standard of care.

And yes I try to avoid doing this, I would rather the operation be one and done

 

[GreenHousePub]

Are we on IPED connect right now?

 

[Bored Snorlax]

Dr Oz would be proud

 

[Feli]

-24 and bill whateva you do (-25 also for proced) for complications not related to typical post-op course.

To avoid problems with that stuff (mods, rejections) on cases known to have ongoing wound care, some DPMs just bill all of those TMA, ray resect, etc as i&d 28003 or toe amp 28820 now (so, no global... can bill debrides, "grafts," other hocus easier post op). That's a gray area, not recommended... but often done... bcuz poe-dye-uh-twee.

...fwiw, Rx abx or PT or DME or normal recovery stuff in the 90d is not qualifying for -24 e/m... that's typical post-op course (and why most real non-podiatry surgeons have midlevels see those 90d global visits).

 

[SubungualDebris]

I usually dictate in my consult note that I expect postoperative wound healing issues that will require local wound care/serial debridements after an amputation due to the patient's past medical history (ie uncontrolled DM, PAD, ESRD on dialysis, etc)

Then bill debridement with -58 modifier when these people inevitably break down or completely dehisce.

 

[Feli]

... I expect postoperative wound healing issues that will require local wound care/serial debridements after an amputation due to the patient's past medical history (ie uncontrolled DM, PAD, ESRD on dialysis, etc)

Then bill debridement with -58 modifier when these people inevitably break down or completely dehisce.

...that's a fine way to go. I usually do the -24 and -25 route (mine is mostly elective/trauma that was expected to heal - but might need some wound care after).

I just use the -58 for DPCs or frame/pin/syndesmotic removals and staged OR stuff. I suppose it works fine for the office 9759x and 1104x to get paid too. Good stuff. Are you in private/collections or hosp/wRVU setup?

 

[DYK343]

I usually dictate in my consult note that I expect postoperative wound healing issues that will require local wound care/serial debridements after an amputation due to the patient's past medical history (ie uncontrolled DM, PAD, ESRD on dialysis, etc)

Then bill debridement with -58 modifier when these people inevitably break down or completely dehisce.

Wait... Im not sure thats how global works. Unless it does work this way. But im pretty sure an op note is not a bypass for a 90 day global on a TMA (with exception of a statement along the lines of staged procedure plan for delayed primary closure once infection resolved, etc)

TMA is my least favorite diabetic procedure because they inevitably require wound care. Rarely does 100% of a TMA take. The 12 RVUs are really not worth it. My wound RNs make the post op visits fast so its not a huge deal but still they should be worth >12RVU.

Or better yet any diabetic amputation, I&D, etc should have no global.

 

[SubungualDebris]

...that's a fine way to go. I usually do the -24 and -25 route (mine is mostly elective/trauma that was expected to heal - but might need some wound care after).

I just use the -58 for DPCs or frame/pin/syndesmotic removals and staged OR stuff. I suppose it works fine for the office 9759x and 1104x to get paid too. Good stuff. Are you in private/collections or hosp/wRVU setup?

I always wonder about trauma/elective cases where patient's have surgical site breakdown requiring serial debridements...I am hesitant to bill for debridements. I feel that surgical site breakdown in these patients can be an expected or reasonably expected postoperative complication and therefore any treatment rendered to address this issue would be part of the postop global. IDK, maybe I have been playing it too safe.

I am part of a private Ortho group, I receive 100% of my collections.

 

[DYK343]

I always wonder about trauma/elective cases where patient's have surgical site breakdown requiring serial debridements...I am hesitant to bill for debridements. I feel that surgical site breakdown in these patients can be an expected or reasonably expected postoperative complication and therefore any treatment rendered to address this issue would be part of the postop global. IDK, maybe I have been playing it too safe.

I am part of a private Ortho group, I receive 100% of my collections.

Near 100% of these get sent to the local wound center by the ortho group.
They (typically) are not managing these global wounds.

I get a ton of ankle fxs w dehiscence from ortho.
Its a bit annoying. But whatever. I know how to manage it and it pays the bills. 🦞

 

[SubungualDebris]

Wait... Im not sure thats how global works. Unless it does work this way. But im pretty sure an op note is not a bypass for a 90 day global on a TMA (with exception of a statement along the lines of staged procedure plan for delayed primary closure once infection resolved, etc)

TMA is my least favorite diabetic procedure because they inevitably require wound care. Rarely does 100% of a TMA take. The 12 RVUs are really not worth it. My wound RNs make the post op visits fast so its not a huge deal but still they should be worth >12RVU.

Or better yet any diabetic amputation, I&D, etc should have no global.

Take a look at medicare's definition of the 58 modifier.

"Appropriate use​

Report when a procedure or service during the postoperative period was:
-Planned prospectively or at the time of the original procedure.
-More extensive than original procedure.
-For therapy following a diagnostic surgical procedure.
-When performing a second or related procedure during the postoperative period."

A debridement with 58 modifier performed after a TMA that has broken down, especially in patient's who have PAD, ESRD, uncontrolled DM, is reasonable to bill if you have dictated and made the patient aware that it will likely require serial treatments after the index procedure due to expected surgical site breakdown as a result of their medical comorbidities.

See below for Medicare's own example of a toe amputation that went on to needed a TMA (this was when toe amputations had a 90 day global, but you get the point)

"Example
A patient with diabetes and advanced circulatory problems had a gangrenous toe removed from her left foot on February 5, 2022. At the time of the surgery, the physician advised of the possibility of amputating the left foot due to her condition. On February 26, 2022, the physician performed an amputation of the left foot.

Bill as follows:

Procedure code 28820 (amputation of the toe) (90 global surgery period), date of service February 5, 2022."
Procedure code 28805 (amputation thru the metatarsal) with modifier 58, date of service February 26, 2022.
Documentation must substantiate the use of modifier 58.

 

[Adam Smasher]

Wasn't 2022 the year they changed 28820 to a 0-day global?

 

[SubungualDebris]

LOL yes, I pointed that out in my reply. Substitute toe amp for ray amp. You get the picture.

 

[heybrother]

What's interesting to me is Novitas is somewhat inconsistent in how they display the rules related to 58 ie. in one ruling they provide simply a list and in another they include "or". I had wondered on first glancing at this if we somehow needed to meet every criteria below - ie. an "and" scenario as opposed to an "or" scenario as they show in the second document. "And" would be problematic because a debridement will almost always be less extensive than the original procedure.

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[air bud]

78 modifier is for wound care clinic ... And if you look at things it says basically operating room or specialized procedure room and so one thing that I've wondered is a wound care clinic considered a specialized procedure room.... No one's going there just to have a non-surgical blood pressure check or talk about their mental health.... Sounds like I am going to start actually doing a little bit less at the wound care clinic we have a new guy coming in and I think I'm going to basically be able to punt all my global dehist people to him and he will gladly take them. Then I can truly do surgical consultations. In theory how it should be. Podiatrist addresses biomechanics decides who need surgery and who doesn't and then other wound care providers can do serial debridements and dressing changes. I don't need to breed a wound weekly, I just need to decide who just needs surgical intervention right away to fix the ulcer and who can wait or doesn't need it at all for a variety of reasons.... But we all know our skill set is valuable and how much time we can save patients by walking in seeing an ulcer getting a little bit of HPI and saying that's not going to heal until I do surgery on you, you do surgery and then it's healed in 3 to 4 weeks and you just saved them 4 months in a wound care center.

 

[Feli]

I always wonder about trauma/elective cases where patient's have surgical site breakdown requiring serial debridements...I am hesitant to bill for debridements. I feel that surgical site breakdown in these patients can be an expected or reasonably expected postoperative complication and therefore any treatment rendered to address this issue would be part of the postop global. IDK, maybe I have been playing it too safe.

I am part of a private Ortho group, I receive 100% of my collections.

I will def bill it if any dehiscence or hematoma etc... the few times I have not, it's more that I'm trying not to inflame the pt as the case has gone sideways and im being nice. It's legit to bill for any significant wound issues on bunion or calc fx or etc, though.

Those aren't normal healing (but prob wise to not bill aggro on a Lapidus where you're looking at the plate and you know pt isn't happy and/or hasn't met deductible.