Rule Category:

Billing

` Ref: No:
2012-BR-0007

Version Control:
Version No. 3.0

Effective Date:
08 December 2012

Revision Date:
August 2015

Wound Care Management

Adjudication Rule
Table of content
Abstract Scope Adjudication Policy Adjudication examples Denial codes Appendices
Page 1 Page 2 Page 2 Page 5 Page 5 Page 5

Approved by:
Daman

Abstract Responsible:
Medical Strategy &
Development Department
For Members
Related Adjudication
Billing Rules are the adjudication rules, which are in compliance with official CPT, ICD-CM Rules:
and HAAD/CCSC coding guidelines. None
A billing rule defines the minimum requirements to be met when a service is claimed for
a Daman beneficiary in terms of frequency, duration etc. Disclaimer
It explains the minimum required documentation to claim a service. It also defines the By accessing these Daman Adjudication Rules (the
“AR”), you acknowledge that you have read and
coverage of a service under a particular insurance plan administered by Daman. understood the terms of use set out in the
disclaimer below:
The information contained in this AR is intended to
outline the procedures of adjudication of medical
For Medical Professionals claims as applied by the National Health Insurance
Company – Daman PJSC (hereinafter “Daman”).
The AR is not intended to be comprehensive,
The scope of this guideline is to describe the proper coding and reporting requirements should not be used as treatment guidelines and
should only be used for the purpose of reference
for wound care management. or guidance for adjudication procedures and shall
not be construed as conclusive. Daman in no way
Daman covers wound care management for all health insurance plans, subject to policy interferes with the treatment of patient and will
not bear any responsibility for treatment decisions
terms and conditions and if billing methodology is clinically appropriate in terms of interpreted through Daman AR. Treatment of
patient is and remains at all times the sole
diagnosis, frequency and duration. responsibility of the treating Healthcare Provider.
This AR does not grant any rights or impose
obligations on Daman. The AR and all of the
information it contains are provided "as is"
without warranties of any kind, whether express
or implied which are hereby expressly disclaimed.
Under no circumstances will Daman be liable to
any person or business entity for any direct,
indirect, special, incidental, consequential, or
other damages arising out of any use of, access
to, or inability to use or access to, or reliance on
this AR, including but without limitation to, any
loss of profits, business interruption, or loss of
programs or information, even if Daman has been
specifically advised of the possibility of such
damages. Daman also disclaims all liability for
any material contained in other websites linked to
Daman website.
This AR is subject to the laws, decrees, circulars
and regulations of Abu Dhabi and UAE. Any
information provided herein is general and is not
intended to replace or supersede any laws or
regulations related to the AR as enforced in the
UAE issued by any governmental entity or
regulatory authority, or any other written
document governing the relationship between
Daman and its contracting parties.
This AR is developed by Daman and is the
property of Daman and may not be copied,
reproduced, distributed or displayed by any third
party without Daman’s express written consent.
This AR incorporates the Current Procedural
Terminology and Current Dental Terminology
(CPT® and CDT®, which is a registered
trademark of the American Medical Association
(“AMA”), and the American Dental Association
(“ADA”) respectively), and the CPT and CDT codes
and descriptions belong to the AMA. Daman
reserves the right to modify, alter, amend or
obsolete the AR at any time by providing one
month prior notice.

National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
Doc Ctrl No.: TEMP/MSD-004 Version No.: 1 Revision No.: 0 Date of Issue: 08.05.2013 Page No(s).: 1 of 5
Wound Care Management

Scope (blistering), and third degree (full-thickness

involvement).
The scope of this guideline is to describe the proper
coding and reporting requirements of wound care. Billing and documentation requirements:

Wounds can be categorized as traumatic and non-  Code the site, degree and extend of burn,
traumatic. documented in the medical record

 Traumatic wounds are mainly acute (include  Classify burns of the same local site (three-digit
lacerations, abrasions, cellulitis, burns etc) and category level, 940-947) but of different
chronic (like Ulcers) in nature degrees to the subcategory, identifying the
highest degree recorded in the diagnosis. Non-
 A non-traumatic wound includes surgical wound healing burns are coded as acute burns
dehiscence
 Necrosis of burned skin should be coded as a
The ICD coding and CPT coding rules varies non-healed burn
according to the nature of wound.
 Code 958.3, Post-traumatic wound infection, not
elsewhere classified, as an additional code, only
if infected burn site is documented
Adjudication Policy
 Category 949, Burn, unspecified, is extremely
vague term and should rarely be used
Eligibility / Coverage Criteria
Wound care management is covered for all health 3. Coding for Cellulitis
insurance plans administered by Daman, subject to
Coding of cellulitis secondary to superficial injury,
policy terms and conditions and if the billing
burn, or frostbite requires two codes, one for the
methodology is clinically appropriate in terms of
injury and one for the cellulitis.
diagnosis, frequency and duration.
Sequencing of codes depends on the circumstances
of the admission.
Requirements for Coverage
Billing and documentation requirements:
ICD diagnosis coded to highest level of specificity
as documented in the medical record of the patient.  Code cellulitis only if documented in the medical
record

Non-Coverage  Code 958.3, Post-traumatic wound infection,

NEC, should not be assigned if the infection is
ICD-9-CM code(s) not covered by the individual’s identified as cellulitis
policy or is/are clinically in-appropriate in terms of
diagnosis, frequency and duration.  Cellulitis described as gangrenous is classified to
code 785.4, Gangrene

Payment and Coding Rules 4. Coding for Wound Disruption

ICD – CM Coding rules are as given below:  998.31 Disruption of internal operation wound
 998.32 Disruption of external operation wound
1. Coding for Injuries
Code for the most serious injury, as determined by
the provider and the focus of treatment is CPT-4 and Service Codes Coding Rules are given
sequenced first. below:

Billing and documentation requirements: 1. Debridement

 Code only those injuries, documented in the
medical record. It is the removal of foreign material and/or
devitalized or contaminated tissue from or adjacent
 Assign a single code for each injury, only when a to a traumatic or infected wound until surrounding
combination code is not available healthy tissue is exposed.
 Do not code superficial injuries when associated Active wound care management
with more severe injuries of the same site
Definition: Debride the wound of devitalized tissue,
 Always code E code to show the cause and place cleanse the wound, promote coverage of the
of occurrence of the injury dermal defect, and to restore function to the tissue
and surrounding area. Includes following:
2. Coding for Burns
 Selective (97597 – 97598)
Burn codes (940-948) are classified by depth,
extent and by agent (E code). Burns are classified  Non selective ( 97602)
by depth as first degree (erythema), second degree
 Negative pressure ( 97605- 97606)

National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
Doc Ctrl No.: TEMP/MSD-004 Version No.: 1 Revision No.: 0 Date of Issue: 08.05.2013 Page No(s).: 2 of 5
Wound Care Management

 Surgical debridement (Excisional) (11000- instructions provided to the patient on the date
11001 and 11042 – 11047) of the service. Only significantly separately
identifiable service are performed and
 Pressure ulcers (15920-15958)
reasonable as well as distinct, from the
 Burn wounds (16020-16030) debridement service(s) provided a separate E/M
can be claimed.
Billing and documentation requirements:
Surgical debridement (Excisional)
 These codes are normally to be reported by
non-physician professionals (e.g. physician Billing and documentation requirements:
assistants, nurse practitioners, enterostomal
 The debridement code submitted should be
therapy nurses, wound care nurses, physical
based on the type and amount and the surface
therapists) licensed to perform these
area of tissue removed, not based on the depth,
procedures. Report these codes by physician
size, or other characteristics of the wound.
only if debridement of skin performed which is
Document should support coded anatomical site,
limited to epidermis and/or dermis.
area of body surface debrided and or extent of
 Include assessment of the wound, the technique tissue or foreign material debrided (e.g. if a
of debridement (selective or nonselective) with wound involves exposed bone but the
or without out the use of minimal anesthesia, debridement procedure did not remove bone,
cleansing of the wound, dressing of the wound CPT code 11044 cannot be billed).
(including application of topical ointments,
 When performing debridement of a single
wound bed protection and bulk dressing), and
wound, report depth using the deepest level of
any patient/family instruction.
tissue removed. In multiple wounds, sum the
 Examination of wound to assess the drainage, surface area of those wounds that are at the
color, texture, temperature, vascularity, same depth, but do not combine sums from
condition of surrounding tissue, and size of the different depths.
area to be targeted for debridement of necrotic
 For debridement of skin, i.e., epidermis and/or
tissue.
dermis only, see 97597, 97598.
 When debridement is performed, the
 Dressings applied to the wound are part of the
debridement procedure notes must document
service for CPT codes 11000-11001 and 11042-
tissue removal (i.e. skin, full or partial
11047 and they may not be billed/ reimbursed
thickness; subcutaneous tissue; muscle; and/or
separately.
bone), the method used to debride, and the
character of the wound (including dimensions,  The use of CPT codes 11042-11047 is not
description of necrotic material present, appropriate for the following services: washing
description of tissue removed, degree of bacterial or fungal debris from feet, paring or
epithelialization, etc.) before and after cutting of corns or calluses, incision and
debridement. drainage of abscess including paronychia,
trimming or debridement of nails, avulsion of
 Do not report both selective and nonselective
nail plates, acne surgery, destruction of warts,
debridement codes for techniques performed on
or burn debridement. Report these procedures,
the same devitalized tissue area(s) of a wound
when they represent covered, reasonable and
on the same date of service.
necessary services, using the CPT code that
 The application and removal of dressings most closely describes the service supplied.
associated with these debridement techniques is
 E/M codes are not usually billed in conjunction
considered part of the work associated with the
with a surgical debridement code. Surgical
procedures and, therefore, would not be
debridement code includes the pre-debridement
reported separately. If a dressing change is
wound assessment, the debridement, and the
performed without any active wound care
post-procedure instructions provided to the
management (debridement), then it is not be
patient on the date of the service. Only
appropriate to use the wound care management
significantly separately identifiable service are
codes to describe the service.
performed and reasonable as well as distinct,
 Generally, 97022 (whirlpool) and 97597/97598 from the debridement service(s) provided a
should not be reported during the same separate E/M can be claimed.
encounter, since the whirlpool is a component of
 Codes 11040-11044 are considered complex
the 97597/97598 codes.
surgical services performed by physicians.
 Do not report 97597-97606 codes with 11042 –
11047. Pressure Ulcers
 E/M codes are not usually billed in conjunction Billing and documentation requirements:
with an active wound care management code
 Selecting the code depends on, whether it was
Active wound care management code includes
excision or a debridement.
the pre-debridement wound assessment, the
debridement, and the post-procedure

National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
Doc Ctrl No.: TEMP/MSD-004 Version No.: 1 Revision No.: 0 Date of Issue: 08.05.2013 Page No(s).: 3 of 5
Wound Care Management

 If physician debrides the ulcer, effectively or general anesthesia. Document should justify
removing it and allowing the wound to stay open medical requirement for performing dressing
to heal, then code (11040-11044). If the under anesthesia. E.g. severe crush injuries
physician excises the ulcer, clears all infection where serial tissue debridement is required and
and closes the wound, then the appropriate code also for certain types of infection.
from the decubitus ulcer category should be
Evaluation and Management Codes:
used.
 When service provided is only a non-surgical
 Pressure ulcer is differentiated by location
cleansing of a wound without sharp
(coccygeal, sacral, ischial and trochanteric),
debridement, with or without the application of
primary suture or flap closure with skin flaps
a surgical dressing, the appropriate Evaluation
and with or without ostectomy.
and Management (E/M) codes should be used.
 The document should support the anatomical
 The selection of the E/M service should be
site, flap, graft, closure and or ostectomy.
supported by the documentation of the
 E/M codes are not usually billed in conjunction appropriate components; and the non-surgical
with a pressure ulcer excision code. CPT code cleansing of a wound will be considered bundled
includes the pre-debridement wound in the E&M reimbursements, and has no
assessment, the debridement, and the post- entitlement for separate payment.
procedure instructions provided to the patient
on the date of the service. Only significantly 3. Service codes for Non-surgical cleansing of
separately identifiable service are performed a wound (51-01, 51-02 and 51-03)
and reasonable as well as distinct, from the
debridement service(s) provided a separate E/M Billing and documentation requirements:
can be claimed.  Report only when performed in the “Follow up
 Dressings applied to the wound are part of the within one week” period, non-surgical cleansing
CPT code and need not to be reported. of a wound without sharp debridement with or
without local anesthesia.

Burn Wounds (16000-16030)  Do not report with wound debridement, dressing

for burns, and dressing change under anesthesia
 The procedure codes 16000-16042 are to be other than local on the same encounter.
used to report the local treatment of the burn
wound itself. Medical justification for performing such a
procedure needs to be documented with the length
 These codes do not include evaluation and of surgical dressing applied.
management services. The usual pre- and post-
procedural services (e.g. explaining procedures
to the patient/family, supervising the positioning
and prepping of patient; monitoring stability of
Adjudication Examples
the patient, as appropriate; and after care
instruction) are included in the procedure code Example 1
and not reported separately. Question: Below claim is reported by a network
 The degree of the burn, percentage of body provider to Daman for a Thiqa patient. Are these
surface involved (typically using the Rule of services payable?
Nines should be documented in the patients
Code Description
chart. The depth of the burn also needs to be
documented. Erythema due to burn (first degree),
944.13 (ICD-9) two or more digits, not including
 Dressings applied to the wound are part of the thumb
CPT code and need not to be reported. 10-19% of body burned; third degree
948.1 (ICD-9) less than 10%, not present, or
2. Dressing change
unspecified
Dressing change (for other than burns), under Accident caused by hot (boiling) tap
E924.2 (ICD-9)
anesthesia (other than local) (15852). water
Injury or poisoning occurring at/in the
Billing and documentation requirements: E849.0 (ICD-9)
home
 As per AMA, dressing changes other than under Initial treatment, first degree burn,
local anesthesia do not have separate CPT codes 16000 (CPT) when no more than local treatment is
and are included when an E/M code is reported. required
99213 (E/M) Consultation
 If a procedure is performed on the same day
dressing will be part of that procedure. E.g. Answer: yes, all of the above services are payable
Laceration repairs, debridement etc. as they are clinically appropriate in terms of
diagnosis, frequency and duration.
 CPT Code 15852 is reported normally when
physician changes a dressing on a wound other
than a burn while the patient is under sedation
National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
Doc Ctrl No.: TEMP/MSD-004 Version No.: 1 Revision No.: 0 Date of Issue: 08.05.2013 Page No(s).: 4 of 5
Wound Care Management

Example 2 B. Revision History

Question: Below claim is reported by a provider to
Date Change
Daman for a UAE Plan patient with the ICD-9 CM
codes 924.20, E888.9, and E849.0. The CPT4 codes V 2.0: New template
reported are CPT 15852 & SRVC 10. Can these 01-07-13
Coding rules updated
services be paid?
1. V 3.0
Code Description 15-07-14 2. Disclaimer updated as per system
requirements
924.20 (ICD-9) Contusion of foot

E888.9 (ICD-9) Unspecified fall

Injury or poisoning occurring at/in the

E849.0 (ICD-9)
home
Dressing change (for other than
15852 (CPT) burns), under anaesthesia (other than
local)

99213 (E/M) Consultation

Answer: Daman will deny the CPT code 15852, as

this service is clinically not appropriate in terms of
diagnosis and will be rejected with denial code
MNEC-003.

Denial codes
Code Code description
MNEC-004 Service is not clinically indicated based
on good clinical practice, without
additional supporting diagnoses/activities

MNEc-005 Service/supply may be appropriate, but

too frequent

MNEC-003 Service is not clinically indicated based

on good clinical practice

DUPL-002 Payment already made for same/similar

service

PRCE-002 Payment is included in the allowance for

another service

Appendices

A. References
1. CCSC Coding Manual 2012
2. AMA CPT Assistant,2007
3. AMA CPT Book 2012
4. HAAD Claims and Adjudication Rules V2012-
Q2
5. American Health Information Management
Association - Audio Seminar/Webinar 2008
6. ICD-9-CM Official Guidelines for Coding and
Reporting 2011

National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
Doc Ctrl No.: TEMP/MSD-004 Version No.: 1 Revision No.: 0 Date of Issue: 08.05.2013 Page No(s).: 5 of 5