How’s Your Debridement Coding?


Vol. 18 • Issue 23 • Page 8
CCS Prep!

Excisional debridement has long been an inpatient coding area of interest, due to the fact that its inclusion on a case can increase DRG relative weight, and thus reimbursement, significantly. It’s also become one of the most lucrative review issues for the recovery audit contractor (RAC) audits, as confirmed in the RAC demonstration project in California, New York and Florida. Those cases with inappropriate assignment of code 86.22, Excisional debridement of wound, infection, or burn, netted nearly $67 million in inappropriate payments, by far the largest single coding issue to translate to recoverable funds. Before the RAC program is implemented nationwide in 2010, savvy coding professionals must bone up on all the guidelines, tips and traps associated with coding excisional debridement.

Overview

Issues related to the appropriate coding of skin and subcutaneous tissue debridement have historically been difficult. Debridement that is classified as “excisional” must be documented as such by the person performing the debridement. Terms such as “sharp debridement” or the use of scissors or a scalpel alone are not considered sufficient for code assignment as excisional debridement. The other crucial factor for appropriate code assignment is depth of excision. Code 86.22 should be assigned only for debridement procedures involving the skin and subcutaneous tissue. But coders should also ensure that the debridement is invasive enough to meet the definition of excisional. Procedures performed to remove slough, devitalized tissue and necrosis by such methods as brushing, irrigation (e.g., whirlpool), scrubbing or washing are considered non-excisional debridement and should be assigned to code 86.28, Non-excisional debridement of wound, infection, or burn.

The differentiation between excisional and non-excisional debridement is particularly important from a reimbursement standpoint, because code 86.22 (excisional debridement) is considered a valid operating room (OR) procedure that affects DRG assignment, and code 86.28 (non-excisional debridement) is not. Procedures involving debridement of skin and subcutaneous tissues, but also involving bone, muscle, tendon or fascia should be classified elsewhere. In addition, debridement procedures performed as a component of an amputation, incision and drainage, bursectomy, or hip repair/revision should not be coded separately. The debridement is considered an inherent component of the primary procedure. While excisional debridement is considered a valid OR procedure, it may be performed in a variety of settings, and it’s not required that it be performed in an operating room setting.

It appears some review organizations were interpreting the coding advice in Coding Clinic literally, such as requiring documentation of excisional debridement involve cutting outside or beyond the wound margins. This issue was clarified in the 1st Quarter 2008 issue of Coding Clinic, where it was stated that the clinical information in Coding Clinic is provided to aid in the coder’s understanding only and was not intended as clinical criteria.

Affect on DRG Assignment

The tables presented below (additional tables are on our Web site at www.advanceweb.com/him) provide examples of DRG effect when codes 86.22, Excisional debridement, vs. 86.28, Non-excisional debridement, or debridement of other tissue sites are assigned for typical cases involving debridement services. As mentioned before, the issue of inappropriately coded excisional debridement services has netted the RAC audit demonstration project the highest return on investment, due to the fact that not only are these very commonly performed procedures, but many of these patients have multiple underlying conditions, some of which are designated as MCCs. Note: assume a national average base rate of $5,124.56 and an additional MCC code for the examples given.

MDC 8 Diseases and Disorders of the Musculoskeletal System and Connective Tissue

Diagnosis codes:

• 730.16 Chronic osteomyelitis of the lower leg

• MCC condition

Procedure codes:

• 86.22 Excisional debridement of wound, infection, or burn

OR

• 86.28 Non-excisional debridement of wound, infection, or burn

Diagnosis codes:

• 728.3 Muscle disorders, NEC

MCC condition

Procedure codes:

• 86.22 Excisional debridement of wound, infection, or burn

OR

• 83.45 Debridement of muscle, NOS

OR

83.39 Excision of lesion of other soft tissue (fascia debridement)

As the tables above demonstrate, debridement services are

provided for a wide variety of conditions that are found in many different MDCs. This is why it’s crucial for all inpatient coding

professionals to understand all guidelines and regulatory information related to excisional debridement coding. Visit this CCS Prep! article on our Web site at www.advanceweb.com/him for a table that provides a list of the Coding Clinic references related to excisional debridement. After review of these issues, test yourself with the following quiz:

1. The procedure note indicates that the physician debrided a coccyx wound with sharp excision down to and including the fascia and bone. How should the debridement down to the bone be coded?

a. 86.22

b. 86.22, 77.69

c. 86.22, 77.69, 83.39

d. 77.69

2. A patient with recent history of amputation of the right third, fourth and fifth toes was admitted with increasing cellulitis and infection of the amputation site. The progress notes indicate a sharp scalpel excisional debridement of necrotic skin and tissue at the amputation site was performed at bedside on the fourth day of hospitalization. How should this amputation site debridement be coded?

a. 86.22

b. 84.3, 86.22

c. 84.3

d. 84.11

3. A patient with a recent history of circumferential full thickness

burns involving the right upper extremity presents with wound eschar. The physical therapy notes indicate that a debridement escharotomy

was performed. Based on this documentation, the appropriate procedure code(s) is/are?

a. 86.22

b. 86.28

c. 86.09

d. 86.3

4. A patient has an excisional debridement of the right buttock (down to the muscle) and left leg, involving only skin and subcutaneous tissue. How should this surgical episode be coded?

a. 86.22

b. 86.22, 83.45

c. 77.69, 83.45

d. 86.22, 83.39

This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com). Ingenix is a leader in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Coding Clinic for ICD-9-CM is published quarterly by the AHA.

Answers to CCS PREP!: 1. d. Assign code 77.69, Local excision of lesion or tissue of bone, other, for the sharp debridement of the fascia down to the bone. When multiple layers of the same site are debrided, assign only a code for the deepest layer of debridement. Refer to Coding Clinic, First Quarter 1999, pp 8-9, for additional information regarding extensive wound debridement; 2. a. Code 86.22 should be assigned for the excisional debridement of subcutaneous tissue and skin. Code 84.3 is not appropriate, because the procedure did not involve the resection of bone and would not be considered a stump revision. Code 84.11 is also not appropriate because there was no further amputation procedure performed, 3. c. Refer to Coding Clinic, 4th Quarter, 2000, page 68: Prior to Oct. 1, 2000, escharotomy was indexed to 86.22, Excisional debridement of wound, infection or burn. This code assignment has been re-evaluated and escharotomy has been re-indexed to code 86.09, Other incision of skin and subcutaneous tissue; and 4. b. Two codes should be assigned because the patient had two different sites debrided. Assign code 83.45, Other myectomy for the buttock debridement and code 86.22, Excisional debridement of wound, infection, or burn for the leg debridement.

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