Monthly Hyperbaric Compliance Series
April 2008
Referral of a Compromised Toe Amputation
This is one referral condition that continues to cause diagnosis, coding and compliance issues, particularly regarding Medicare beneficiaries.
Key to determining the correct course of action from an insurance compliance perspective is whether or not the surgeon closed the amputation site primarily, commonly with a skin flap.
- If the referred compromised amputation site is a guillotine type (left open – no
skin rotated for primary coverage purposes) it is coded as 997.60 (Amputation
stump complication; unspecified) or 997.62 if infection is evident (and an additional
code should identify the organism). Under these circumstances no indication for
HBO therapy exists from a Medicare point of view. Attempts to treat such Medicare
beneficiaries using codes 996.52 (compromised skin flap when no skin flap was
employed) or 250.7/707.15 (diabetic wounds of the lower extremity) have resulted
in post-payment demands for claim repayment. A compromised open amputation, particularly
in the setting of reversible local hypoxia, may be worthy of a pre-authorization
request from non-Medicare health insurance companies.
- If a toe amputation site is closed primarily with a (usually rotational)
skin flap, and is subsequently considered to be at risk or otherwise compromised,
then a ‘medically necessary’ condition exists for the Medicare patient.
It is a compromised skin flap and should be coded as 996.52. The same applies
to non-Medicare patients although pre-authorization is recommended but should
not delay institution of HBO therapy. It is the position of the Undersea and
Hyperbaric Medical Society that:
- “Adjunctive HBO therapy can reduce costs by salvaging skin grafts,
flaps…”
- “To be maximally effective, HBO therapy should be started as soon as signs of flap compromise appear”
‘A picture is a thousand words’, particularly when dealing with insurance denials or demands for repayments. One cannot overestimate the value of serial wound photography.