General Surgery Coding Alert

"When a coccygeal decubitus ulcer is excised or debrided, the patients coccyx may also be removed to relieve pressure on the ulcer. Normally, this procedure is billed using either the debridement or decubitus ulcer excision codes. In some cases, however, neither the excision nor the debridement codes in the integumentary section of CPT most accurately describe the services performed, as in the following case study.

Note: For more information on debridement and decubitus ulcer excision codes, see General Surgery Coding Alert, March 2001.

Operative Report

Preoperative diagnosis: Coccygeal decubitus with gangrene and invasive infection.

Postoperative diagnosis: Same.

Procedure: Wide debridement of coccygeal decubitus with excision of coccyx and drains to the presacral space.

History: This 97-year-old man has been progressively worsening over the last six months and has not been eating well for the last two to three months. He has had a coccygeal decubitus and trochanteric decubitus. The coccygeal decubitus developed a foul odor and black discoloration over the last two to three days. He was brought to surgery for debridement.

Operative Findings: The patient has an approximately 10-cm x 10-cm area of necrosis with black discoloration and foul odor extending onto the fascia around the sacrum and coccyx. It appeared to tunnel anterior to the sacrum along the coccyx. The patient also shows some beginning black discoloration of the superficial muscle of the gluteus. [The discoloration] does not appear to go down around the rectum.

Operative procedure: With the patient in the left lateral decubitus position, partially on his stomach, the sacral area and buttocks were prepped and draped. The area circumferentially was infiltrated with Marcaine 0.5 percent with Epinephrine and Xylocaine 2 percent with Epinephrine mixed 50/50. The skin was then excised about 1 cm back from the edge with cutting current electrocautery. It became obvious that it was going back to skin subcutaneous tissue that was viable. He still has some black discoloration extending along the fascia of the gluteus muscle and bone. This was all debrided. Some undermining of the skin was left because it was widely drained. The coccyx was excised to allow draining of the presacral space. Although there was no necrotic tissue in the presacral space there was some turbid fluid and a cavity of 3 to 4 cm was identified and drained. Hemostasis was obtained with electrocautery and the wound observed for a couple of minutes. It was then packed with 2-inch Iodoform gauze and fluffs. An elastic dressing was placed around the lower abdomen and sacral area. The patient was then removed from the operating room and recovered in surgery prior to being transferred back to his room.

Use Musculoskeletal Code

In this case the coccygeal decubitus ulcer was not excised because the wound was kept open due to the presence of infection. Therefore, 15920 (excision, coccygeal pressure ulcer, with coccygectomy; with primary suture) and 15922 ( with flap closure) do not apply, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill. The debridement codes also do not describe the procedure because they make no mention of the coccygectomy.

Rather, 27080 (coccygectomy, primary) from the musculoskeletal section of CPT accurately describes the procedure as documented, Mueller says. She cites the codes descriptor in Medicodes Coders Desk Reference, which specifies, the coccyx is freed from surrounding soft tissue and then disarticulated from the sacrum. If no pressure sore infection is present, the incision is repaired in multiple layers using sutures, staples, and/or Steri-strips. If infection is present, the physician may pack the wound with gauze, allowing the wound to heal by granulation tissue from within.

Although the decision to leave the wound open to facilitate healing rules out 15920 or 15922, this is not the most compelling reason for choosing 27080, says Marcella Bucknam, CPC, billing and compliance coordinator at the University of Nebraska Medical Centers department of surgery in Omaha.

To decide whether 15920, 15922 or 27080 is correct, you must determine the intent of the surgery, Bucknam says. She notes that the primary focus of the procedures described by 15920 and 15922 is the decubitus ulcer: The coccyx is removed to prevent a recurrence of the ulcer due to continuing irritation.

When surgeons perform the procedure described by 27080, however, the coccyx itself is the primary focus. In this case, the surgeon describes a large area of necrosis with black discoloration and foul odor extending down to the coccyx which indicates that the coccyx was infected and explains why it was removed. The debridement of the decubitus ulcer is incidental in that it provides access so that the coccyx can be removed, Bucknam says.

Decubitus ulcer excision codes essentially are skin codes, whereas 27080 is a muscle and bone code. If the coccyx is removed to allow the skin to heal, integumentary codes [here, 15920 or 15922] should be used. But if the infection runs along the bone, which is clearly indicated in this case, a musculoskeletal code [27080] is more appropriate, Bucknam explains.

Had the wound been closed following the coccygeal excision, 27080 would still be a more appropriate code than either 15920 or 15922 because, again, the main focus of the session was to remove the infected coccyx.

Note: ICD-9 code 707.0 (decubitus ulcer) should be linked to 27080 on the HCFA 1500 claim form.

Carefully Document Separately Billed Debridement

The debridement described in the case study is included in 27080. Had the operative report been more detailed, however, the debridement may have possibly been billed using 11043 (debridement; skin, subcutaneous tissue, and muscle), Mueller says.

Incidental debridement normally is considered part of the procedure, Mueller says, but when more than 50 percent of the operative time is required just to get where
you need to go, the debridement may be billed separately with modifier -59 (distinct procedural service). She adds that the scenario is similar to a complex laceration repair in CPT that specifically states if extensive debridement is necessary, it may be separately billed.

Because the debridement described in the cited operative note appears to have been extensive, it might have been separately payable had the additional difficulty and the amount of time spent on the debridement been documented in the operative note, Mueller says. Because neither the time nor the difficulty of the debridement is clearly documented, however, 11043 should not be billed and reimbursement is lost.

If debridement is performed at a separate anatomic location, an addendum may be required to clarify that the debridement being billed is separate from the excision of the coccyx. In addition, modifier -59 would need to be appended to the appropriate debridement code, Mueller says."