Meet Documentation Criteria for Excisional Debridement

Don’t let stringent requirements make you a RAC target.

By Vickie Balistreri, BA, RHIA, CPC, CPC-H, CCS, CCS-P, CCDS

Mark Twain once said, “The difference between the right word and the almost right word is the difference between lightning and the lightning bug.” I think this nicely summarizes the importance of using the “right words” to document excisional debridement.

Five Elements Complete Excisional Debridement Note

Documentation requirements to support excisional debridement coding are very stringent. Perhaps as a result, excisional debridement claims are targeted not only by recovery audit contractor (RAC) audits, but also by the Office of Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS).

Complete documentation for excisional debridement requires five elements:

  1. A description of the procedure as “excisional”
  2. A description of the instrument used to cut or excise the tissue (e.g., scissors, scalpel, curette)
  3. A description of the tissue removed (e.g., necrotic, devitalized or non-viable)
  4. The appearance and size of the wound (e.g., down to fresh bleeding tissue, 7 cm x 10 cm, etc.)
  5. The depth of the debridement (e.g., to skin, fascia, subcutaneous tissue, muscle, or bone)

If any of these elements are missing, documentation does not meet the criteria for excisional debridement, according to RACs (see “RAC Reviewers Hit Hard on Debridement: Five Elements Must Be Documented,” Report on Medicare Compliance, vol. 19, No. 6, Feb. 15). For example, using a sharp instrument does not necessarily indicate that an excisional debridement was performed. Documentation needs to describe the sharp debridement as a definite cutting away of devitalized tissue that includes cutting outside or beyond the wound margin.

Many hospitals and physicians have created templates (like the one shown to the right) to ensure that all of the elements are properly documented.

 

Excisional Debridement Template

Type of debridement (circle one)   excisional  nonexcisional

Size and appearance of wound debrided ______________________________

Removal of devitalized tissue description (necrotic, nonviable, etc.) ______________

Cutting instrument used (scalpel, forceps, scissors, etc.) ____________________

Depth of debridement

(How deep did it go to get to pink, healthy tissue? Circle to deepest depth.)

skin        subcutaneous      muscle  fascia     bone

Selecting CPT® Codes

Prior to Jan. 1, 2011, excisional debridements were reported with code range 11040-11044. Effective Jan. 1, however, codes 11040-11041 were deleted. Instead, for debridement of skin only,see 97597 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less and 97598 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure).

Codes describing excision debridement deeper than skin-only are organized by depth:

  • Subcutaneous tissue (includes epidermis and dermis, if performed) – 11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less and 11045 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
  • Muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed) – 11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less and 11046 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
  • Bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed) – 11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less and 11047 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

Note that these codes are reported by area (sq cm), in addition to depth. For example, a 65-year-old patient with diabetes presents with a 5 cm x 4 cm ulceration (20 sq cm) involving the skin and subcutaneous tissue of the left heel. The physician examines the ulcerated area for size, depth, location, and staging. Using a scalpel, he excises (removes) the necrotic skin and subcutaneous tissues to the level of viable tissue, and then irrigates the wound.

Proper coding in this case is 11042. If the area of the wound was 30 sq cm (e.g., 5 cm x 6 cm), proper coding would be 11042, 11045.

ICD-9 Debridement Procedure Coding

According to the ICD-9-CM Official Guidelines for Coding and Reporting, effective Oct. 1, 2010, “Excisional debridement involves surgical removal or cutting away, as opposed to a mechanical (brushing, scrubbing, washing) debridement. For coding purposes, excisional debridement is assigned to code 86.22. Non-excisional debridement is assigned to code 86.28.”

A change from 86.22 Excisional debridement of wound, infection, or burn to 86.28 Nonexcisional debridement of wound, infection, or burn will make a significant difference in hospital reimbursement under Medicare severity diagnosis-related groups (MS-DRGs).

Nonexcision Debridement Calls for Different Coding

Nonexcisional debridement is described as non-surgical because it does not involve cutting away or excising devitalized tissue. It is described as removal of devitalized tissue, necrosis, and slough by other methods, such as:

  • Scrubbing
  • Washing
  • Water scalpel (jet)
  • Irrigation (under pressure)

Examples of nonexcisional debridement are pulsed lavage, mechanical lavage, mechanical irrigation, high-pressure irrigation, etc. For instance, Versajet™ debridement is always considered nonsurgical, mechanical debridement because it does not involve cutting away or excising devitalized tissue. Likewise, the Arobella Qoustic Wound Therapy System™ uses an ultrasonic assisted curette to mechanically debride wounds.

According to American Hospital Association’s (AHA’s) Coding Clinic for ICD-9-CM, second quarter 2004, debridement performed by physical therapists is generally nonexcisional. Debridement of the skin that is preparatory to further surgery, such as reduction of fracture, should not be coded as a separate procedure.

A CPT® example of nonexcisional debridement is 97602 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session. This code would be used, for example, if a wound is cleaned, evaluated for size, depth, and evidence of ulceration or necrosis, hydrotherapy is used to soften and loosen the tissue, and dressing is applied.

Use E/M Codes for Nonsurgical Cleansing Without Debridement

When the service provided is only a nonsurgical cleansing of a wound without debridement, with or without the application of a surgical dressing, use the appropriate evaluation and management (E/M) code, not a debridement code.

For example, a patient is seen in the office for subsequent wound care. The wound is cleansed with topical ointment. No tissue is removed, and the wound dressing is changed. For this you would report an E/M service, as supported by the level of documentation (e.g., 9921x).

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Vickie Balistreri, BA, RHIA, CPC, CPC-H, CCS, CCS-P, CCDS, is a health care consultant for JA Thomas & Associates-Clinical Documentation Improvement and has 26 years of health care coding and auditing experience. Balistreri is a former AAPC (NAB) member.

 

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2 Responses to “Meet Documentation Criteria for Excisional Debridement”

  1. Shelia says:

    Can you tell me if it is okay to code for an excisional debridement and a removal of hardware:20680?
    There is much debate in out office. Any help would be greatly appreciated. Thanks!

  2. Nicole says:

    Can you please tell me if the physician has to document all the requirements for debridment or can use use nursine notes to find if the patient tolerated the procedure etc? Thank you.

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