Do you wish to offer healthcare services without getting paid for them? No? Exactly, no one wants to remain unpaid or receive less compensation after providing complete services. Applying wrong CPT codes usually results in denials, causes late payments, and sometimes no payment at all. Hence, all healthcare providers must apply correct CPT codes on the claims before submitting to the insurance payer.
But how will you know which CPT code applies to which service? The answer is right here. Our ‘CPT Code’ series. Today, we have chosen CPT code 11045 for a detailed discussion. We will cover every detail of this code, including its correct application to protect you from claim denials.
CPT Code 11045 Description
CPT code 11045 is an add-on code that falls under the ‘Debridement Procedures on the Skin’ code range.
It represents subcutaneous tissue debridement where the provider removes dead tissue from the subcutaneous layer, and epidermis and dermis (only if it is necessary) using surgical tools. This service is performed in the same session as a separately reportable initial 20 cm2 debridement procedure. So, CPT code 11045 indicates an extra 20 cm2 of debrided area.
The “add-on” designation indicates that 11045 must be used in conjunction with a primary procedure code (e.g., CPT code 11042, 11043, or 11044).
The physician performs this procedure to remove diseased or dead tissue from a wound and promote healing.
Scenarios Where CPT Code 11045 is Applicable
The following are some real-life examples for a better understanding of CPT code 11045’s usage.
Debriding Diabetic Foot Ulcers
Every year, 1.6 million people in the U.S. suffer from diabetic foot ulcers, and almost one-third of people with diabetes suffer from foot ulcers in their lifetimes.
Imagine a 65-year-old diabetic man who visits the clinic with a right foot ulcer, measuring 64 cm2, that is not healing. The physician chooses to debride his subcutaneous tissue to promote faster recovery. After debriding the initial 20 cm2, he debrides the remaining 44 cm2 of devitalized subcutaneous tissue and reports it with 3 units of CPT code 11045 (20 cm2 + 20 cm2 + 4 cm2).
Bedsores (Pressure ulcers)
Pressure sores, also referred to as bedsores, are more common in the elderly. This condition affects about 70% of adults over 70.
Suppose a 78-year-old bedridden nursing home resident has a pressure ulcer on her leg measuring 50 cm2. The physician surgically removes the dead tissue from all three layers of the skin (epidermis, dermis, and subcutaneous). Hence, the physician bills the initial 20 cm2 with the primary code and applies 2 units of CPT code 11045 for the remaining 30 cm2 (20 cm2 + 10 cm2).
Venous Ulcer
Venous ulcers are lower leg sores that are formed due to poor blood circulation in the veins. They typically heal more slowly and can sometimes take months to heal. Venous ulcers are the most prevalent kind of chronic lower extremity ulcers, affecting almost 1% to 3% of Americans.
Suppose a 55-year-old woman visits the clinic with a history of valve dysfunction. The physician debrides her ulcer by removing the necrotic subcutaneous tissues from her limb. Since the ulcer is 40 cm2, the physician must apply CPT code 11045 for the additional 20 cm2 of debrided area after the initial 20 cm2.
Traumatic Injury
Let’s suppose a 35-year-old man is involved in a road accident. He sustains severe wounds to his foot and leg. The healthcare provider measures the wound’s surface area, which comes out to be 50 cm2. The physician decides to debride the damaged subcutaneous tissue to prevent bacterial infection and promote healing. He will use the primary code to report the initial 20 cm2 of debrided dead subcutaneous tissue and 2 units of CPT code 11045 for the remaining 30 cm2 (20 cm2 + 10 cm2) of debridement.
Applicable Modifiers for CPT Code 11045
Modifiers are used to provide additional details about the service. This ensures accurate billing and payment, and helps clarify the facts surrounding the service. Modifiers are not applied to add-on codes because they are already free from the multiple procedure notion and are meant to be used in conjunction with the primary code. Instead, adding a modifier would be superfluous or may negatively impact the reimbursement.
Since CPT code 11045 is an add-on code, you can not apply any modifier with this code.
CPT Code 11045 – Billing & Reimbursement Guidelines
You can follow these specific billing and reimbursement guidelines of CPT code 11045 to prevent any potential claim denial.
Ensure Correct Usage of Code
Now that you are aware that CPT code 11045 is an add-on code, you can not bill this code separately. This code must be billed in conjunction with the primary code. However, the debridement procedure must be medically necessary and appropriate for the patient’s condition. Plus, you must ensure accurate measurement of the debrided and devitalized subcutaneous tissue to justify the need for an additional 20 cm2 of surgical removal.
Provide Detailed Documentation
As a healthcare professional, you must be aware of the significance of accurate documentation. Insufficient and inaccurate documentation makes it complicated for billers to prove a procedure’s medical necessity, resulting in denials. In the case of CPT code 11045, the supporting documentation must include the following:
- The wound dimensions (length × width × depth) and total surface area in cm2.
- Accurate location of the wound debridement
- The type of debrided tissue (must be subcutaneous for 11045)
- Medical necessity: Diagnosis and clinical signs of infection, delayed healing, necrosis, or preparation for further procedures.
Follow Payor-Specific Guidelines
You must read and understand the billing guidelines and reimbursement policies specified in the payer’s contract before submitting the claim. Medicare, Medicaid, and most private payers have their own set of rules and reimbursement amounts. Even if it is just Medicare, reimbursement rates will vary based on locality and the setting of your practice. So, we recommend confirming the reimbursement rate for CPT code 11045 for your MAC locality and facility using the PFS Lookup Tool.
Conclusion
In conclusion, you can not bill CPT code 11045 on its own. It is an add-on code, and must be billed with its primary code. Furthermore, you can not apply any modifier with this code because all the necessary modifiers must be appended to the primary code. And lastly, you have to be vigilant during billing, filing claims, and preparing documents, so that essential information, like the medical necessity of the procedure, is conveyed to the payer.
However, if you still think that the information in this guide was not enough and you require extra help, you can acquire wound care billing services from professionals. They can help you file error-free claims, reduce denials, and increase your collections.
