LCD L33614: Debridement Services

Abstract:

Debridement is the removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound. The codes in this local coverage determination (LCD) cover debridement of skin, subcutaneous tissue, fascia, muscle, bone and removal of foreign material. Debridement promotes wound healing by reducing sources of infection and other mechanical impediments to healing. Its goal is to cleanse the wound, reduce bacterial contamination and provide an optimal environment for wound healing or possible surgical intervention. The usual end point of debridement is removal of pathological tissue and/or foreign material until healthy tissue is exposed. Debridement techniques include, among others, sharp and blunt dissection, curettement, scrubbing, and forceful irrigation. Surgical instruments may include a scrub brush, irrigation device, electrocautery, laser, sharp curette, forceps, scissors, burr or scalpel. Prior to debridement, determination of the extent of an ulcer/wound may be aided by the use of blunt probes to determine wound/ulcer depth and to disclose abscess and sinus tracts.

This LCD does not apply to debridement of burned surfaces. Regulations concerning the use of debridement of burned surfaces codes are not addressed in this LCD. This LCD does not apply to debridement of nails and the provider is referred to NGS LCD Routine Foot Care and Debridement of Nails (L33636).

Indications:

Debridement is indicated for any wound requiring removal of deep seated foreign material, devitalized or nonviable tissue at the level of skin, subcutaneous tissue, fascia, muscle or bone, to promote optimal wound healing or to prepare the site of appropriate surgical intervention.

Conditions that may require debridement of large amounts of skin include: rapidly spreading necrotizing process (sometimes seen with aggressive streptococcal infections), severe eczema, bullous skin diseases, extensive skin trauma (including large abraded areas with ground-in dirt), or autoimmune skin diseases (such as pemphigus).

Debridement services for subcutaneous tissue muscle or fascia or bone are appropriate for treatment of skin ulcers, circumscribed dermal infections, conditions affecting contiguous deeper structures, and debridement of deep-seated debris from any number of injury types.

Debridement for osteomyelitis is covered for chronic osteomyelitis and osteomyelitis associated with an open wound.

Debridement of superficial ulcers (skin, dermis and/or epidermis, whenever necrotic tissue is present in an open wound may also be indicated. They may also be indicated in cases of abnormal wound healing or repair. These services will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue.

• The wound care performed must be in accordance with accepted standards of medical practice. If debridement is performed, the type of debridement should be appropriate to the type of wound and the devitalized tissue, and the patient’s condition. Not all wounds require debridement at each session or the same level of debridement at each session. It is unusual to debride more than one time per week for more than three months. A greater frequency or duration of selective debridement should be justified in the documentation. Most very small wounds do not require selective debridement. Ulcers that may require selective debridement are typically larger than 2 x 2 cm. Wounds with tunneling, regardless of size, may require selective debridement. Selective debridement is usually not reasonable and necessary for blisters, ulcers smaller than those described above and uninfected ulcers with clear borders.

• Debridement of the wound(s) if indicated must be performed judiciously and at appropriate intervals. It is expected that, with appropriate care, and no extenuating medical or surgical complications or setbacks, wound volume or surface dimension should decrease over time. It is also expected the wound care treatment plan is modified in the event that appropriate healing is not achieved. It is expected that co-morbid conditions that may interfere with normal wound healing have been addressed; the etiology of the wound has been determined and addressed as well as addressing patient compliance issues. This may include, for example, evaluation of pulses, ABI and/or possible consultation with a vascular surgeon.

The number of debridement services required is variable and depends on numerous intrinsic and extrinsic factors. Debridement services are covered provided all significant relevant comorbid conditions are addressed that could interfere with optimal wound healing.

Limitations:

If there is no necrotic, devitalized, fibrotic, or other tissue or foreign matter present that would interfere with wound healing, the debridement service is not medically necessary. The presence or absence of such tissue or foreign matter must be documented in the medical record.

Debridement area greater than 10% is limited to those practitioners who are licensed to perform surgery above the ankle, since the amount of skin required is more than that contained on both feet.

Skin breakdown under a dorsal corn is not considered an ulcer and generally does not require debridement. These lesions typically heal without significant surgical intervention beyond removal of the corn and shoe modification

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