I have been fighting with UHC Medicare complete regarding them not paying my debridement codes. I billed 11042, and 11045 x 4, wound is 89.10sq cm, dx codes L97.519, l97.919 - Rt leg and foot. I also billed 11043 and 11046 x 5, wound is 109.8sq cm, dx code L97.529, left foot. The debridements were different depths, and obviously in different locations. I have already gone through the appeals process, which means I have sent notes highlighting the types of debridements and location. The claims are still being denied. Is there something else that I am missing or where do I need to go from here?


  • Those ICD-10 codes are not covered. The reason is that you are using an unspecified SEVERITY code.

    For UHC, I started here... and Resources/Policies and Protocols/UnitedHealthcare Medicare Coverage/Skin_Treatment_Procedures_UHCMA_CS.pdf

    This lead me to the CMS Debridement policies.

    Here are some sample LCDs from one of the CMS carriers referenced above...

    You are close but need, for example, L97.511-L97.514, L97.911-914, etc. These are severity-specific.

    You aren't getting paid, because you are using an unspecified code that this carrier won't pay on!

    I hope this helps!


    Karl M. Ellzey, President
    Ellzey Coding Solutions, Inc.
    DermCoder Online coding tools
    10524 Moss Park Rd, Ste 204-314, Orlando, FL 32832
    Toll-free:855.326.3464 p:407.674.2796 f:407.658.8552
  • Karl is correct. As of October 2016 nonspecific codes are huge flags and will hit the NCCI edits when scrubbed by insurances. I'm surprised that you did not get flagged by your software scrubber before it went to the clearing house.  Thanks,
    Elizabeth Stone

    " A bad day is only as bad as you let it be; smile and show the world your better side, and the world just may smile back with you."
  • I guess I should have mentioned that the charges are for August 2016 and that I am in the state of Colorado. The only LCD I found for my area is L35125 and it states that there are no local diagnosis limitations.

    CPT/HCPCS Codes
    Group 1 Paragraph: Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books.

    The following CPT/HCPCS codes associated with the services outlined in this policy will not have local diagnosis limitations applied at this time: 11042, 11043, 11044, 11045, 11046, 11047, 16020, 16025, 16030, 97597, 97598, 97602, 97605, 97606, 97607, 97608, 97610, G0281, and G0329.

    Group 1 Codes:
    XX000 Not Applicable
  • It's still the same reason. You are getting a denial because of the unspecified severity code you are using.

    Use a more specific severity code and it will be paid.

    Karl Ellzey
  • We are having the same problem with our nail debridement's and foot care!

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
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