Performance Improvement 2008. Are Payments for Surgical Removal of Dead or Unhealthy Tissue From Wounds Correct?


This study determined the extent to which Medicare Part B surgical debridement services in 2004 met Medicare program requirements. Surgical debridement is the removal of dead or unhealthy tissue from a wound using a sharp instrument such as a curette or scalpel. The purpose of surgical debridement is to promote wound healing by removing sources of infection and other impediments. Medicare Part B payments for surgical debridement services have increased in recent years. Between 2001 and 2005, Medicare-allowed payments grew 44 percent from $140 million to $202 million. Researchers conducted a medical record review of 368 surgical debridement services from the Centers for Medicare & Medicaid Services' (CMS) National Claims History file that had service dates in 2004. Physicians with experience in wound care and certified professional coders reviewed the records to determine whether they met Medicare program requirements. Researchers interviewed staff from the 17 carriers that processed Part B claims in 2004. Researchers also reviewed the carriers' local coverage determinations that provided additional guidance about surgical debridement services.

Sixty-four percent of surgical debridement services in 2004 did not meet Medicare program requirements, resulting in approximately $64 million in improper payments. Most carriers had local coverage determinations and edits in place but conducted limited medical review of surgical debridement services.

Report Title: Medicare Payments for Surgical Debridement Services in 2004,
Agency Sponsor:
OS-OIG, Office of Inspector General
Federal Contact: Claire Barnard, 202-205-9523
Office of Inspector General
PIC ID: 8780

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"PerformanceImprovement2008.pdf" (pdf, 1.29Mb)

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