Build Up Better Pressure Ulcer Surgery Coding
By G.J. Verhovshek, MA, CPC
Differentiate excision from debridement for proper CPT® assignment.
Bedsores—properly called pressure ulcers or decubitus ulcers—typically result when a patient lies immobile for lengthy periods. The body’s own weight creates pressure points, especially over bony protuberances (such as the coccyx), which restrict blood flow and eventually lead to tissue necrosis. Although easily preventable, severe bedsores may require surgical treatment. Left untreated, bedsores can be fatal.
There are two methods for surgical treatment of bedsores: excision and debridement. When coding a claim for surgical treatment of bedsores, your first task is to determine which method was used by answering the question, “Did the surgeon close the surgical wound?”
- If the surgeon documents immediate or subsequent closure of the surgical wound, he or she performed an excision (15920-15958). This will occur only if the wound shows no signs of infection.
- If the surgeon did not close the surgical wound, he or she performed a debridement (11042-11047). An initial debridement may be followed by subsequent debridement(s), and/or the wound will be allowed to heal by secondary intent.
You’ll Need Three Facts to Code Excision
To select the correct decubitus ulcer excision code, you’ll need to know three things:
- Ulcer location (coccygeal, sacral, ischial, or trochanteric)
- If the surgeon also removed infected bone under the ulcer (ostectomy)
- Method of closure (e.g., primary suture, skin flap, or muscle/myocutaneous flap or skin graft)
Descriptors for excision procedure CPT® codes 15920-15958 specify each of these conditions. For example, the descriptor for 15920 states, “Excision, coccygeal pressure ulcer [location], with coccygectomy [including ostectomy]; with primary suture [method of closure].” Similarly, 15936 specifies, “Excision, sacral pressure ulcer [location], in preparation for muscle or myocutaneous flap or skin graft closure [closure].” There is no mention of ostectomy.
Tip: If the ulcer location is not specified by codes 15920-15958 (i.e., any location other than coccygeal, sacral, ischial, or trochanteric), turn to 15999 Unlisted procedure, excision pressure ulcer. Provider documentation must still specify ulcer location, whether ostectomy occurred, and closure method.
Grafts Are Separate with Excisions
If the surgeon closes the excision wound using free muscle flaps or skin grafts (as in the aforementioned 15936 example), you may report the flap or graft separately. The closure may occur during a subsequent operative session. When this is the case, append modifier 58 Staged or related procedure or service by the same physician during the postoperative period to the appropriate free flap or graft code.
Example: A surgeon excises an ischial pressure ulcer with ostectomy. Several days later, she closes the operative wound by muscle flap. Report the excision with 15946 Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure. You may claim the subsequent muscle flap closure separately with 15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk. Append modifier 58 to show this was a staged (planned) procedure.
Exception: Flaps that remain attached to the donor site may not be reported separately, and should be included in the appropriate “excision with skin flap” code (e.g., 15952 Excision, trochanteric pressure ulcer, with skin flap closure).
Code Debridement by Documented Depth and Area
When reporting debridement of a bedsore, code selection depends on the depth of debridement and total area debrided:
- Depth to subcutaneous tissue (to the depth of blood vessels and nerves): 11042 (first 20 sq cm) and +11045 (each additional 20 sq cm, or part thereof)
- Depth to muscle: 11043 (first 20 sq cm) and +11046 (each additional 20 sq cm, or part thereof)
- Depth to bone: 11044 (first 20 sq cm) and +11047 (each additional 20 sq cm, or part thereof)
The deepest level of tissue removed from a uniquely identifiable wound determines the correct code. For example, do not report 11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less when muscle and tendon are visible, but were not surgically debrided. Nor should you report 11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less when bone is visible, but not documented as part of the surgical debridement. If the operative note is unclear or incomplete, ask the surgeon for details.
Example: A surgeon debrides a 6.0 cm x 6.0 cm bedsore to the depth of bone (total area: 36 sq cm). Report 11044 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).
Remember: If the surgeon performs several debridements over time, and the subsequent debridements occur during the global period of the previous debridements, append modifier 58 to the appropriate subsequent debridement code(s).
Document All Required Elements to Support Debridement Coding
Complete documentation for excisional debridement requires these five elements:
A description of the procedure as “excisional”
A description of the instrument used to cut or excise the tissue (e.g., scissors, scalpel, curette)
A description of the tissue removed (e.g., necrotic, devitalized, or non-viable)
The appearance and size of the wound (e.g., down to fresh bleeding tissue, 7 cm x 10 cm, etc.)
The depth of the debridement (e.g., to skin, fascia, subcutaneous tissue, muscle, or bone)
Tip: 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).
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.