Ulcer Debridement and Ulcer Stages

Reimbursement Policy:
Ulcer Debridement and Ulcer Stages

Effective Date:
February 25, 2019

Last Reviewed Date:
February 23, 2023

Purpose:
This policy provides guidelines for Ulcer Debridement and Ulcer Stages services when appropriately billed by professional providers

Scope:
All products are included, except

Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
COB
ITS Home In-Network
FEP
SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

Definitions:
Stage 1 Pressure Ulcer: Has intact skin. The area may be red, swollen or firm and these signs are considered warning signs of impending tissue breakdown.

Stage 2 Pressure Ulcer: Does not have intact skin but has not penetrated into the subcutaneous tissue. The area may show abrasion, blister or partial thickness skin loss but only involves the epidermis and/or dermis.

Policy:
In accordance with ICD Manual guidelines, Horizon BCBSNJ shall consider for reimbursement procedure codes 11042-11047 (Debridement) when a Stage 1 or Stage 2 diagnosis is billed along with a Stage 3 or 4 Pressure Ulcer diagnosis or with a non-pressure chronic ulcer diagnosis.

Horizon BCBSNJ shall not consider for reimbursement procedure codes 11042-11047 (Debridement) when billed with a Stage 1 or Stage 2 diagnosis only.

Example:
If 11043 (Debridement, muscle and/or fascia) is billed for a stage 3 pressure ulcer of the right hip (ICD-10 code L89.213), then the procedure and the diagnosis do not correspond to the same ulcer stage. Since the pressure ulcer was reported as stage 3, then the debridement procedure will be changed to 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) to correspond to the stage of the ulcer reported.

The CPT® codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon BCBSNJ shall reimburse procedure codes 11042-11047 when billed with a Stage 1 or Stage 2 pressure ulcer diagnosis along with a Stage 3 or Stage 4 pressure ulcer diagnosis or with a non-pressure chronic ulcer diagnosis is not reported on the claim. Reimbursement shall be at the applicable Horizon BCBSNJ fee schedule amount.

Horizon BCBSNJ shall deny 11042-11047 (Debridement) when billed with a Stage 1 or Stage 2 pressure ulcer diagnosis and another pressure ulcer stage (3 or 4) or a non-pressure chronic ulcer diagnosis is not reported on the claim.

No additional reimbursement will be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In denied instances where the provider is participating, no member liability shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
Mandated or legislative required criteria will always supersede.

History:
10/25/2017: Policy approved

CPT® is a registered trademark of the American Medical Association.

Policy 110_v2.0_02232023