For the purpose of reimbursement, a debridement is defined as the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. This medical policy applies to debridement of localized areas such as wounds and ulcers. It does not apply to the removal of extensive eczematous or infected skin.

Debridement is indicated whenever necrotic tissue is present on an open wound. Debridement may also be indicated in cases of abnormal wound healing or repair. Debridement techniques usually progress from nonselective to selective but can be combined. Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue.

Debridement is used in the management and treatment of wounds or ulcers of the skin and underlying tissue. Providers should select a debridement method most appropriate to the type of wound, the amount of devitalized tissue, and the condition of the patient, the setting, and the provider’s experience.

Selective debridement refers to the removal of specific, targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue. Occasional bleeding and pain may occur. The routine application of a topical or local anesthetic does not elevate active wound care management to surgical debridement. Selective debridement includes selective removal of necrotic tissue by sharp dissection including scissors, scalpel, and forceps; and selective removal of necrotic tissue by high-pressure water jet. Selective debridement should only be done under the specific order of a physician.

Local infiltration, metacarpal/digital block or topical anesthesia are included in the reimbursement for debridement services and are not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.

The following services are not considered to be debridement:

• Removal of necrotic tissue by cleansing, scraping (other than by a scalpel or a curette), chemical application, and wet-to-dry dressing.
  
  
• Washing bacterial or fungal debris from lesions.
  
  
• Removal of secretions and coagulation serum from normal skin surrounding an ulcer.
  
  
• Dressing of small or superficial lesions.
  
  
• Trimming of callous or fibrinous material from the margin of an ulcer.
  
  
• Paring or cutting of corns or non-plantar calluses. Skin breakdown under a dorsal corn that begins to heal when the corn is removed and shoe pressure eliminated is not considered an ulcer and does not require debridement unless there is extension into the subcutaneous tissue.
  
  
• Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Providers should report these procedures, when they represent covered, reasonable and necessary services, using appropriate codes.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.

Debridement services are not expected to be medically necessary more frequently than once a week. The rationale and medical necessity for more frequent services must be clearly documented in the medical record.

If the debridement of chronic ulcers requires more than eight services to promote healing, the rationale and medical necessity must be clearly documented in the medical record.

Debridement services reported for ineligible conditions will be considered not medically necessary.  A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Documentation Requirements

The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available on request.

The patient’s record must indicate in the progress notes or procedure notes a detailed description of the procedure and method used, the size, depth, (or grade) and appearance of the ulcer or wound as well as the type of tissue or material removed.

Active debridement performed by a physical therapist must be performed under a treatment plan as any other physical therapy service outlining specific goals, duration, frequency, modalities, an anticipated endpoint, and other pertinent factors as they may apply. Departure from this plan must be documented.

Documentation for debridement exceeding Utilization Guidelines must include a complete description of the wound, progress towards healing, complications that have delayed healing, and a projected number of additional treatments necessary.

When hydrotherapy (whirlpool) is billed by a physical therapist with codes 97597 or 97598, the documentation must reflect that the skillset of a physical therapist was required to perform this service in the given situation.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in this policy have been met.