CCS Prep

How's Your Debridement Coding?

Posted on Nov. 17, 2008

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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 provide examples of DRG affect 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 below:

Examples:

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

Procedure code: 86.22

Procedure code: 86.28

DRG 463: Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC

DRG 539: Osteomyelitis with MCC

Relative Weight: 4.6947

Relative Weight: 2.0287

Reimbursement: $24,058.27

Reimbursement: $10,396.19

Difference in Reimbursement: $13,662.08

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)

Procedure code: 86.22

Procedure code: 83.45 or 83.39

DRG 463 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC

DRG 500 Soft Tissue Procedures with MCC

Relative Weight: 4.6947

Relative Weight: 2.8415

Reimbursement: $24,058.27

Reimbursement: $14,561.44

Difference in Reimbursement: $9,496.83

Diagnosis codes:

·        730.03 Acute osteomyelitis of forearm

·        MCC condition

Procedure codes:

·        86.22 Excisional debridement of wound, infection, or burn

OR

·        77.63 Local excision of lesion or tissue of bone; radius and ulna (bone debridement)

Procedure code: 86.22

Procedure code: 77.63

DRG 463 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC

DRG 495 Local Excision and Removal Internal Fixation Devices Except Hip and Femur with MCC

Relative Weight: 4.6947

Relative Weight: 3.1741

Reimbursement: $24,058.27

Reimbursement: $16,265.87

Difference in Reimbursement: $7,792.40

MDC 9 Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast

Diagnosis codes:

·        707.10 Chronic ulcer of lower limb, unspecified

·        MCC condition

Procedure codes:

·        86.22 Excisional debridement of wound, infection, or burn

OR

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

Procedure code: 86.22

Procedure code: 86.28

DRG 573 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC

DRG 592 Skin Ulcers with MCC

Relative Weight: 3.1932

Relative Weight: 1.7515

Reimbursement: $16,363.74

Reimbursement: $8,975.67

Difference in Reimbursement: $7,388.07

Diagnosis code:

·        682.6 Cellulitis and abscess of leg, except foot

·        MCC condition

Procedure codes:

·        86.22 Excisional debridement of wound, infection, or burn

OR

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

Procedure code: 86.22

Procedure code: 86.28

DRG 573 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC

DRG 602 Cellulitis with MCC

Relative Weight: 3.1932

Relative Weight: 1.4033

Reimbursement: $16,363.74

Reimbursement: $7,191.30

Difference in Reimbursement: $9,172.44

Diagnosis code:

·        682.6 Cellulitis and abscess of leg, except foot

·        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)

Procedure code: 86.22

Procedure code: 83.45 or 83.39

DRG 573 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC

DRG 579 Other Skin, Subcutaneous Tissue and Breast Procedures with MCC

Relative Weight: 3.1932

Relative Weight: 2.7946

Reimbursement: $16,363.74

Reimbursement: $14,321.10

Difference in Reimbursement: $2,042.64

MDC 18 Infectious and Parasitic Diseases

Diagnosis code:

·        998.59 Other postoperative infection

·        MCC condition:

Procedure codes

·        86.22 Excisional debridement of wound, infection, or burn

OR

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

Procedure code: 86.22

Procedure code: 86.28

DRG 856 Postop/Post-traumatic Infections with O.R. procedure with MCC

DRG 862 Postop/Post-traumatic Infections with MCC

Relative Weight: 4.7522

Relative Weight: 1.9142

Reimbursement: $24,352.93

Reimbursement: $9,809.43

Difference in Reimbursement: $14,543.50

MDC 21 Injury, Poisoning and Toxic Effects of Drugs

Diagnosis code:

·        881.10 Open wound of forearm, complicated

·        MCC condition

Procedure codes:

·        86.22 Excisional debridement of wound, infection, or burn

OR

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

Procedure code: 86.22

Procedure code: 86.28

DRG 901 Wound Debridements for Injuries with MCC

DRG 913 Traumatic Injury with MCC

Relative Weight: 3.9888

Relative Weight: 1.2304

Reimbursement: $20,440.84

Reimbursement: $6,305.26

Difference in Reimbursement: $14,135.58

 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. The table below provides a list of the Coding Clinic references related to excisional debridement. After review of these issues, test yourself with the following quiz.

Coding Clinic

Issue

1st Qtr 2008, 3

1st Qtr 1999, 8

Debridement of fascia down to bone; debridement of multiple layers of the same site; levels of debridement

1st Qtr 2008, 3

 

Documentation regarding cutting outside the wound margins - coders' informational purposes only

3rd Qtr 2006, 19

Excisional debridement with Vacuum Assisted Closure (VAC)

2nd Qtr 2006, 11

Excisional debridement with Graftjacket® Xpress

1st Qtr 2005, 14

Excisional debridement of necrotic tissue around an amputation site

4th Qtr 2004, 138

2nd Qtr 2000, 9

Debridement services provided by providers other than physicians

2nd Qtr 2004, 5

Excisional versus nonexcisional debridement

3rd Qtr 2002, 23

Excisional debridement with Oasis ™ graft/wound dressing

4th Qtr 2000, 68

Excisional debridement versus escharotomy

2nd Qtr 1992, 17

3rd Qtr 1989, 16

Laser debridement of decubitus ulcer/wound down to bone

3rd Qtr 1991, 19

Overview of excisional versus nonexcisional debridement

Questions

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 (http://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
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.

4. b. Two codes should be assigned since 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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