Review Results for Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, if Performed); First 20 Square Centimeters or Less – CPT 11042

Background

In an effort to reduce the Part B CERT error rate, the MR Department conducted a service specific post payment review of CPT code 11042 (Debridement, subcutaneous tissue first 20 sq cm or less). The primary focus of these audits was to determine whether the medical necessity of the services billed was at the correct code per Medicare guidelines.

National Government Services randomly selected 377 claims billed for CPT 11042 for post payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

• CPT code 11042 (Debridement, subcutaneous tissue first 20 sq cm or less)

Results

Decision	Number of Claims
Allow	199
Deny	46
Partially Deny	3
Non-Responsive Denial	129

 

• 240 claims from Illinois with 115 allowed and 125 denied for a claims error rate of 52.08%
• 66 claim from Minnesota with 41 allowed and 25 denied for a claims error rate of 37.88%
• 71 claims from Wisconsin with 43 allowed and 28 denied for a claims error rate of 39.44%

Key reasons services were denied

• Documentation did not support medically necessity due to one or more of the following: records did not include some or all of the required elements including presence or absence of foreign material; devitalized or nonviable tissue present or removed during debridement; control of infection and appropriate debridement.
• Documentation was insufficient or incomplete
• Failure to respond to the request for documentation

Recommendations

• Send the requested records within the requested time frame to avoid a denial for no documentation
• Familiarize yourself with available removal of benign skin lesions use guidelines and other CMS publications listed below
• Share this information with your coding personnel to ensure they are properly billing before sending the claim to Medicare.
• If you feel your application of this code is correct, ensure your documentation supports your usage.

Related Content

• CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16: Section 120 Cosmetic Surgery
• Local Coverage Article Billing and Coding: Debridement Services A56617
• Local Coverage Determination: Debridement Services L33614
• National Correct Coding Initiative Policy Manual Chapter 3
• Title XVIII of the Social Security Act 1862(a)(1)(A)
• Title XVIII of the Social Security Act 1833(e)

Posted 4/26/2022