acceptable documentation: debridement
We have a couple newer (to us) coders that we are working with recently and they are repeatedly asking for queries on debridement when we would not typically place them. Here are a couple example scenarios:
1. Provider titles the OP note as an Excisional Debridement. in the narrative he states that he used a scalpel and debrided to the level of Sub Q tissue.
- coder states that she would like a query for type of debridement. When questioned, she states that she cannot code off the title of the procedure and the provider does not state excisional in the narrative
2. Provider titles the OP note 'wide debridement of L foot including skin, sub-q tissue and fat'. In the narrative the provider states: 'Using sharp dissection, the necrotic skin edges were completely debrided. The area of debridement extended approximately 4 cm x 3 cm on the dorsal aspect of the foot. I used a curette to clean the base of the wound laterally, the wound tunneled and pus was found in this area. Wound cultures were then sent. I curetted the entire wound and debrided the skin edges to healthy bleeding tissue'. We also have an 'immediate post op note' (this is the document the provider drafts at the time of surgery that is I quick summery of the procedure (procedure performed, blood loss, complications, etc) that that it was an excisional debridement, down into the fat/subq layers using scissors, scalpel and curette.
- coder requests a query for type of debridement because this distinction is not in the narrative and states she can not use the 'immed post op note' to code.
Both coders are stating that this is guidance being given from the outside company that provides coding auditing services for our facility. I am confused. I believe that in the first scenario that though we should not simply code a debridement base don a title alone, the title is consistent with what is described in the narrative. I would be comfortable coding this a an excisional debridement as is (w actually have this clarified in the immed post op note as well which she also states can't be coded from). In the second scenario, I don't understand why the immed post-op note cant be used to support this documentation? They are being told that basically ONLY the narrative portion of the OP note can be used for coding. The immediate post op note is written at the time of surgery and signed by the surgeon. We actually include a prompt for debridements in the note as a way to ensure the documentation is clarified (without needing a query). Why is this not valid for coding of the procedure? furthermore, how would a query be different? Our query includes the exact same information as the immed post-op note (in regards to the debridement) and is also not part of the narrative OP note. So why would a query be 'code-able' and the immediate post-op note not be?
I am wondering how you view documentation of procedures out of the narrative documentation in a procedure note?
FTR: I know that if the title/other documentation is inconsistent with the narrative, the narrative would be what was coded (or a query should be placed). For ex: if they title the procedure a 'debridement' and describe an incision and drainage (or vice versa) we would need to query to clarify or code the I&D. but I am curious about documentation that is consistent.
thanks so much!
Comments
Yes, I have contacted our coding manager. I was just also curious if there is any support for this idea that I am be aware of. Or (or course) anything that clearly supports my position....
thanks again!
Kathyrn,
Our coders always query on debridement if they do not see "excisional debridement" stated in the operative description. They have also said they cannot code from the operative list along & must have a matching description. Below is a CC they have referenced to me.
I hope it helps.
Cheree
Excisional Debridement Definition
Coding Clinic, Third Quarter ICD-10 2015 Pages: 4-5 Effective with discharges: October 7, 2015
Question:
Can you clarify what determines that a debridement in ICD-10-PCS is excisional? The progress note states: "I have debrided the abscess cavity, removing necrotic tissue and bone by sharp debridement." Does the word "excision" need to be present as with ICD-9-CM?
Answer:
Yes, the documentation standard for coding excisional debridement in ICD-10-PCS is the same as it is for ICD-9-CM. As with ICD-9-CM, the words "sharp debridement" are not enough to code the root operation Excision. A code is assigned for excisional debridement when the provider documents "excisional debridement," and/or the documentation meets the root operation definition of "excision" (cutting out or off, without replacement, a portion of a body part).
© Copyright 1984-2016, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.thanks Cheree!
My coders sent me this one too ;-)
but that coding clinic specifically states that the code for excisional debridement is assigned when EITHER the provider states excisional OR the documentation meets the root operation definition of excision (cutting off a portion of a body part). They do not actually have to say excision in I-10.
That being said, we actually do have excision stated in the immed post-op note in both the cases I am describing. I am unclear why this document would be viewed any different than a query. I guess I am not really understanding why a coder would say 'it has to be in the body of the procedure note' but then accept a query response as code-able. The query response is not in the body of the note either....
thanks again for responding!
Using the current CC from 2015 for excisional debridement as your guide, would you code the following as excisional debridement?:
"material was expressed. This was cultured. The area was then gentlydebrided
using curets and a rongeur. All purulent and necrotic tissue was removed."
Thanks,
Donna
Thank you all. This has now sparked a meeting with my coders to make sure we can stand up to audits when using this coding clinic. According to the coders, some payers are denying things that follow CC to the letter of the law so to speak. I'll update this group once we've done that.
Donna