by M. Bradford Henley, MD
M. Bradford Henley, MD, is the Orthopaedic Trauma Association's representative to the Committee on CPT and ICD Coding.
As of Jan. 1, 1997, there are three new CPT codes describing debridement associated with open fractures and dislocations. These new codes have been established to differentiate open fracture debridement from other debridement procedures reported by CPT codes 11042-11044, such as debridement of leg ulcers, diabetic foot problems or infected wounds.
According to the Physicians' Current Procedural Terminology, published by the American Medical Association, "The type of fracture (e.g., open, compound, closed) does not have any coding correlation with the type of treatment (e.g., closed, open or percutaneous) provided. The codes for treatment of fractures and joint injuries (dislocations) are categorized by the type of manipulation (reduction) and stabilization (fixation or immobilization). These codes can apply to either open (compound) or closed fractures or joint injuries."
Open fractures and/or dislocations can be defined as where the bone and/or joint is exposed to the external environment, or when the fracture or dislocation is caused by blunt or penetrating force sufficient to disrupt or penetrate skin, subcutaneous tissue, muscle fascia, muscle, and/or the bone or joint. Open fractures are often contaminated by foreign material (e.g., clothing, grass, dirt, gravel), dead or devitalized tissue and bacteria.
In 1993, all codes for treatment of open/compound fractures were deleted from the CPT manual because the amount of work or intensity required to treat the associated soft tissue injuries varied widely and could not be captured by a single code. Also, the treatment of the fracture or dislocation was essentially the same whether it was open or closed. This was not true, however, for the accompanying soft tissue injuries or contamination. In fact, in open fractures, wound treatment may sometimes be more time-consuming and require more work than the treatment of the fracture itself. Debridement may be carried out several times before and after definitive fracture treatment is performed. Therefore, CPT allows debridement procedures to be coded separately with fracture treatment.
In 1995, the Medicare five-year review of physician work values examined CPT codes 11043-11044. Because of the significant difference in the way orthopaedic surgeons used these codes compared to other specialties, the AMA/Specialty Society RVS Update Committee (RUC) recommended that new CPT codes be developed.
In February 1996, the AMA CPT Editorial Panel accepted a proposal from the Academy and the Orthopaedic Trauma Association for three new codes for debridement of open fractures. These codes are:
11010 Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues
11011 skin, subcutaneous tissue, muscle fascia and muscle
11012 skin, subcutaneous tissue, muscle fascia, muscle and bone
These codes have been placed in the Integumentary System section of the CPT manual, along with other debridement codes. In addition, minor revisions have been made to the guidelines under the heading "Repair (Closure)" to direct the coder to the new fracture debridement codes.
Debridement procedures may be repeated as often as necessary to obtain a clean wound before, during or after appropriate fracture treatment. When an initial debridement or fracture treatment is followed at a later date by repeated debridement or definitive fracture treatment, the modifier -58 (staged procedures) should be appended to the codes reported for the procedures performed at the later operative session. This modifier indicates that the second procedure was planned prospectively or was more extensive than the original procedure.
In patients with more than one open fracture or dislocation, two or more debridement codes may be reported in a single surgical session. The multiple procedure modifier -51 should be appended to the additional debridement procedures. This modifier also should be used when debridement is reported at the same operative session as fracture/dislocation treatment, or neurovascular, tendon or ligament repair. Modifier -51 should not be used when a single fracture debridement is the only procedure reported.
Debridement codes not associated with fractures (11040-11044) can be reported with fracture debridement codes (11010-11012) in those multiple trauma patients who have a combination of open wounds with open fractures or dislocations, and without fractures or dislocations, in different anatomic sites. Again, the multiple procedure modifier -51 should be appended to all secondary procedures.