debridement
Hi,
Need some advice on what procedure code this would code to and whether an excisional/nonexcisional query is required:
Background: pt comes in for L knee nonhealing wound/infected (s/p injury a few wks ago - simple cut then eventually + purulent drainage). Pt with severe RA - on prednisone and methotrexate. R/o osteo. Post procedure, MD documenting "surgical debridement". Gram stain growing GNR so far, ID pending.
Per op report:
"after induction of general anesthesia and sterile prep and drape, i went ahead and debrided the wound. i sent cultures and debrided all necrotic looking material down to the capsule of the knee. however, it did not penetrate the knee. it was all bone. the tissue underneath looked good and viable. i then packed the wound..."
Need some advice on what procedure code this would code to and whether an excisional/nonexcisional query is required:
Background: pt comes in for L knee nonhealing wound/infected (s/p injury a few wks ago - simple cut then eventually + purulent drainage). Pt with severe RA - on prednisone and methotrexate. R/o osteo. Post procedure, MD documenting "surgical debridement". Gram stain growing GNR so far, ID pending.
Per op report:
"after induction of general anesthesia and sterile prep and drape, i went ahead and debrided the wound. i sent cultures and debrided all necrotic looking material down to the capsule of the knee. however, it did not penetrate the knee. it was all bone. the tissue underneath looked good and viable. i then packed the wound..."
Comments
Mark
Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org
http://www.sibley.org
-
Elizabeth Hynd RN, BSN, CPUR
Clinical Documentation Specialist
863-687-1100 ext. 7313
>>> CDI Talk 11/2/2012 1:10 PM >>>
If you had documentation of the instrument, it would be much easier to determine. I believe a query is indicated, and ask for the instrument(s) used, though it reads like it was excisional debridement.
Mark
Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org
http://www.sibley.org
Dorie
CC
S
Reference:
VOLUME 25 FIRST QUARTER
NUMBER 1 2008, Page 3
Excisional Debridement
The Central Office has received numerous questions about the information published in Coding Clinic Second Quarter 2004, page 5, which stated that excisional debridement involves cutting outside or beyond the wound margin. Healthcare facilities have stated that some local review organizations are interpreting this information literally. Coders are seeking clarification whether excisional debridement must involve cutting outside or beyond the wound margin and if the provider's documentation needs to specifically state this in order to assign code 86.22.
The clinical information published in Coding Clinic regarding excisional debridement and cutting outside of the wound margins was provided for informational purposes to aid the coder's understanding. It was not intended as clinical criteria to report code 86.22. The establishment of clinical parameters for code assignment is beyond the scope of authority of the Editorial Advisory Board for Coding Clinic for ICD-9-CM. All code assignment is based on provider documentation. Clear and concise documentation is required in order to accurately report excisional debridement. The link between good provider documentation and correct coding has always been emphasized in Coding Clinic. It is critical that hospitals work with their providers to ensure that the documentation used to support excisional debridement clearly describes the procedure performed. Documentation of excisional debridement should be very specific regarding the type of debridement. If the documentation is not clear or there is any question about the procedure, the provider should be queried for clarification.
The following questions and answers are examples related to coding excisional debridement:
Question: On the wound progress note the physician documented that an excisional debridement was carried out. Would this be coded as excisional debridement?
Answer: Yes, assign code 86.22, Excisional debridement of wound infection or burn.
Question: The physician debrided a coccyx wound with sharp excision down to the fascia and bone. How should the debridement down to the bone be coded?
Answer: 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, pages 8 to 9, for additional information regarding extensive wound debridement.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01D04B8C.B23E33F0]
This is an old chart that was denied because excisional debridement was coded. I agree that the documentation should have been clarified. Not only was excisional debridement not fully described but he titled his procedure note 'irrigation and debridement'. I don't think excisional debridement should have been coded.
We have a couple physicians that have recently expressed their frustration with excisional debridement queries and when we got this denial I was hoping to use it as an example for why this documentation clarification is important. I was hoping for a clear cut excisional debridement that just wasn't labeled as such or something like this but this isn't quite so simple (of course).
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, February 18, 2015 4:08 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Debridement
Based on the information provided, I'd code excision of lesion of bone w/ sharp instrument - would not use w/ any other code as this is the 'deepest' layer excised. Code = 77.69
Reference:
VOLUME 25 FIRST QUARTER
NUMBER 1 2008, Page 3
Excisional Debridement
The Central Office has received numerous questions about the information published in Coding Clinic Second Quarter 2004, page 5, which stated that excisional debridement involves cutting outside or beyond the wound margin. Healthcare facilities have stated that some local review organizations are interpreting this information literally. Coders are seeking clarification whether excisional debridement must involve cutting outside or beyond the wound margin and if the provider's documentation needs to specifically state this in order to assign code 86.22.
The clinical information published in Coding Clinic regarding excisional debridement and cutting outside of the wound margins was provided for informational purposes to aid the coder's understanding. It was not intended as clinical criteria to report code 86.22. The establishment of clinical parameters for code assignment is beyond the scope of authority of the Editorial Advisory Board for Coding Clinic for ICD-9-CM. All code assignment is based on provider documentation. Clear and concise documentation is required in order to accurately report excisional debridement. The link between good provider documentation and correct coding has always been emphasized in Coding Clinic. It is critical that hospitals work with their providers to ensure that the documentation used to support excisional debridement clearly describes the procedure performed. Documentation of excisional debridement should be very specific regarding the type of debridement. If the documentation is not clear or there is any question about the procedure, the provider should be queried for clarification.
The following questions and answers are examples related to coding excisional debridement:
Question: On the wound progress note the physician documented that an excisional debridement was carried out. Would this be coded as excisional debridement?
Answer: Yes, assign code 86.22, Excisional debridement of wound infection or burn.
Question: The physician debrided a coccyx wound with sharp excision down to the fascia and bone. How should the debridement down to the bone be coded?
Answer: 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, pages 8 to 9, for additional information regarding extensive wound debridement.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01D04C13.8BF0FB60]
Thanks Paul,
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, February 19, 2015 9:53 AM
To: Kathryn Good
Subject: RE: [cdi_talk] Debridement
I hope the 3rd party did allow for code 77.69?
I think the record clearly documents a surgical tool was used to resect portion of the bone - the code for that = 77.69. A code for 86.22 should not be assigned, but only the code for the procedure described at the 'deepest' level of tissue (bone), further stated as a resection with rongeur.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01D04F38.703D8FF0]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, February 19, 2015 6:13 AM
To: Evans, Paul
Subject: RE: [cdi_talk] Debridement
Thank you everyone for your feedback.
This is an old chart that was denied because excisional debridement was coded. I agree that the documentation should have been clarified. Not only was excisional debridement not fully described but he titled his procedure note 'irrigation and debridement'. I don't think excisional debridement should have been coded.
We have a couple physicians that have recently expressed their frustration with excisional debridement queries and when we got this denial I was hoping to use it as an example for why this documentation clarification is important. I was hoping for a clear cut excisional debridement that just wasn't labeled as such or something like this but this isn't quite so simple (of course).
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, February 18, 2015 4:08 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Debridement
Based on the information provided, I'd code excision of lesion of bone w/ sharp instrument - would not use w/ any other code as this is the 'deepest' layer excised. Code = 77.69
Reference:
VOLUME 25 FIRST QUARTER
NUMBER 1 2008, Page 3
Excisional Debridement
The Central Office has received numerous questions about the information published in Coding Clinic Second Quarter 2004, page 5, which stated that excisional debridement involves cutting outside or beyond the wound margin. Healthcare facilities have stated that some local review organizations are interpreting this information literally. Coders are seeking clarification whether excisional debridement must involve cutting outside or beyond the wound margin and if the provider's documentation needs to specifically state this in order to assign code 86.22.
The clinical information published in Coding Clinic regarding excisional debridement and cutting outside of the wound margins was provided for informational purposes to aid the coder's understanding. It was not intended as clinical criteria to report code 86.22. The establishment of clinical parameters for code assignment is beyond the scope of authority of the Editorial Advisory Board for Coding Clinic for ICD-9-CM. All code assignment is based on provider documentation. Clear and concise documentation is required in order to accurately report excisional debridement. The link between good provider documentation and correct coding has always been emphasized in Coding Clinic. It is critical that hospitals work with their providers to ensure that the documentation used to support excisional debridement clearly describes the procedure performed. Documentation of excisional debridement should be very specific regarding the type of debridement. If the documentation is not clear or there is any question about the procedure, the provider should be queried for clarification.
The following questions and answers are examples related to coding excisional debridement:
Question: On the wound progress note the physician documented that an excisional debridement was carried out. Would this be coded as excisional debridement?
Answer: Yes, assign code 86.22, Excisional debridement of wound infection or burn.
Question: The physician debrided a coccyx wound with sharp excision down to the fascia and bone. How should the debridement down to the bone be coded?
Answer: 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, pages 8 to 9, for additional information regarding extensive wound debridement.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01D04F38.703D8FF0]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, February 18, 2015 2:47 PM
To: Evans, Paul
Subject: Re: [cdi_talk] Debridement
I think it would be helpful to know what instrumentation he used to achieve the sharp debridement-? Scalpel and as you stated the statement of "excisional". I think it could possibly be an excisional debridement to the level of the bone, given it states he sent bone and soft tissue and removed bone with a rongeur. He doesn't state this is for biopsy of bone, but could be to possibly definitively rule out osteomyelitis, etc. Was it sent for Pathology, Micro, or both? Possibly procedure code 77.69 -Local excision of lesion or tissue of bone.-used for debridement procedures that extend to bone. Could also be biopsy of bone in addition to excisional debridement depending on level of actual debridement-86.22 & 77.49?
Thanks,
Melissa Windau, BSN,RN,CDM
Sent from my iPhone
On Feb 18, 2015, at 5:17 PM, "CDI Talk" wrote:
I need a second opinion.
Op note looks like this:
The wound was explored. This wound
basically went down onto the lateral distal wall of the calcaneal tuberosity. The surrounding
tissues were somewhat chronic appearing with poorly vascularized tissue. Sharp debridement of
the peripheral wound took down the edges to healthier appearing tissue and fat. The wound was
extended proximally so that I could access the lateral wall of the calcaneal tuberosity more
freely. Retractors were placed and I explored the lateral calcaneus. I did not find any signs
of bone lysis or pockets of necrotic or infected bone. His cortex was intact surrounding this
whole area and into the plantar lateral calcaneal tuberosity. I did use a rongeur to resect a
small amount of bone in the area contiguous with his previous wound. The bone was sent as a
deep culture and some soft tissue resected from the peripheral wound was sent for superficial
tissue culture. The wound was then irrigated with pulse lavage, using 3 liters of sterile
saline. The wound VAC was then placed on the lateral wound.
In your opinion does this describe an irrigation and debridement or an excisional debridement (I realize the MD has to say excisional)? Something else?
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
---
Syndi Hudson, RN, CCDS,CCM
CHRISTUS Santa Rosa New Braunfels
CDI Specialist
cynthia.hudson@christushealth.org
830-643-6116 (Office)
830-643-5139 (Fax)
“We are His hands”. Isaiah 64:8
Excisional and Nonexcisional Debridement
Coding Clinic, Third Quarter 2015: Page 3
Coding advice or code assignments contained in this issue effective with discharges October 7, 2015.
Debridement of the skin and subcutaneous tissue is a procedure by which foreign material and devitalized or contaminated tissue are removed from a traumatic or infected lesion until the surrounding healthy tissue is exposed.
Excisional debridement of the skin or subcutaneous tissue is the surgical removal or cutting away of such tissue, necrosis, or slough and is classified to the root operation “Excision.” Use of a sharp instrument does not always indicate that an excisional debridement was performed. Minor removal of loose fragments with scissors or using a sharp instrument to scrape away tissue is not an excisional debridement. Excisional debridement involves the use of a scalpel to remove devitalized tissue. Documentation of excisional debridement should be specific regarding the type of debridement. If the documentation is not clear or if there is any question about the procedure, the provider should be queried for clarification. A code is assigned for excisional debridement when the provider documents “excisional debridement, & rdquo; and/or the documentation meets the root operation definition of “Excision” (cutting out or off, without replacement, a portion of a body part).
Nonexcisional debridement of the skin is the nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis, slough, or foreign material. Most nonexcisional debridement procedures are classified to the root operation “Extraction” (pulling or stripping out or off all or a portion of a body part by the use of force).
Question:
On the wound care progress note the physician documented that an excisional debridement of the skin of the buttock was carried out. Would this be coded as excisional debridement?
Answer:
Yes, assign code 0HB8XZZ, Excision of buttock skin, external approach, for the excisional debridement of skin of the buttocks.
Question:
The physician performed excisional debridement of a coccyx wound down to the fascia and including bone. How should this debridement be coded?
Answer:
Assign code 0QBS0ZZ, Excision of coccyx, open approach. When multiple layers of the same site are debrided, assign only a code for the deepest layer of debridement.
Question:
In terms of coding excisional debridement, does dissection mean the same as excisional? For example, the provider’s documentation states: “The debridement was sharp using knife dissection.”
Answer:
No, knife dissection is not sufficient language to be able to code the root operation “Excision.” Knife dissection may only be referring to the means used to reach the procedure site, and doesn’t necessarily say what was done at the site. Query the physician for more information when the documentation only states knife dissection. Use of a sharp instrument does not always indicate that an excisional debridement was performed. 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). Documentation of excisional debridement should be specific regarding the type of debridement. If the documentation is not clear or if there is any question about the procedure, the provider should be queried for clarification.
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).
Question:
The patient developed a nonhealing necrotic ulcer of the right thigh. Using a VersaJet debrider, the physician performed debridement of the skin and subcutaneous tissue. How should this procedure be coded?
Answer:
Assign code 0HDHXZZ, Extraction of right upper leg skin, external approach, for the nonexcisional debridement using VersaJet. The VersaJet is a device consisting of an ultra high-pressure generator with a console and disposable attachments. A natural vacuum created by the jet stream removes tissue fragments. The device has specialized features that allow physicians to debride traumatic wounds, chronic wounds, or other soft tissue lesions and aspirate and remove contaminants or other debris. Debridement with Versajet debrider is coded as nonexcisional debridement.
Question:
In the discharge summary the physician describes the patient’s debridement: “The patient underwent a digressive debridement by physical therapy of her sacral decubitus with pulse lavage and wet-to-dry dressing changes...” Should this procedure be coded as an excisional debridement or a nonexcisional debridement?
Answer:
Assign code 0HD6XZZ, Extraction of back skin, external approach, for the procedure performed.
The pulsed lavage digressive debridement is considered nonsurgical mechanical debridement. It does not involve cutting away or excising devitalized tissue. In pulsed lavage, an irrigating solution (or irrigant) is delivered under pressure along with suction. Pulsed lavage is used for the debridement of bone and tissue for wound cleansing in order to remove infectious agents and debris. This method of wound cleansing is also known as “mechanical lavage,” “pulsatile lavage,” “mechanical irrigation,” and “high-pressure irrigation.” This type of debridement is coded as nonexcisional debridement with the root operation “Extraction.” The instrument used in the debridement extracts loose tissue, and involves more than simple irrigation. Therefore the correct root operation is “Extraction” rather than “Irrigation.”
Question:
The patient presents for surgical treatment of a necrotizing soft tissue infection of the left buttock. The provider documented the following in the operative note: “Using a sharp scalpel, I first connected the abscess sites and excised down through the subcutaneous tissue with electrocautery. The tissue was in the process of liquefying and was nonviable. The wound measured 8 cm wide by 4 cm long and 2.5 cm deep, and was extensively excised.” In this case, the physician does not explicitly document “excisional debridement,” however the documentation meets the root operation definition of “Excision.” What is the correct ICD-10-PCS code assignment for the procedure?
Answer:
Assign the following ICD-10-PCS code for the excisional debridement of the buttock:
0JB90ZZ
Excision of buttock subcutaneous tissue and fascia, open approach
The ICD-10-PCS Official Guidelines for Coding and Reporting (A11) states, “Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.”
Question:
If a physician documents “debridement of bone, fascia or muscle,” without specifying “excisional debridement,” can that be reported as excisional debridement? In order for the surgeon to get down into these areas, wouldn’t he or she need to excise/cut? What code should we report for debridement performed on bone, muscle or fascia, if not specified as excisional?
Answer:
Coders cannot assume that the debridement of bone, fascia, or muscle is always excisional. For example, if a patient suffers a traumatic open wound and fascia, muscle, or bone is exposed, an excisional debridement may not be performed. ICD-10-PCS does not provide a default if the debridement is not specified as “excisional” or “nonexcisional.”
In many cases, only nonexcisional debridement is required to clean the wound. Therefore, providers should specifically document the type of debridement. Clear and concise documentation is needed in order to accurately report excisional debridement. The link between good provider documentation and correct coding has always been emphasized in Coding Clinic. It is critical that hospitals work with their providers to ensure that the documentation used to support excisional debridement clearly describes the procedure. Although this may pose some challenges to the coding community, if the documentation is not clear or there is any question about the procedure, the provider should be queried for clarification. To avoid queries, which are frustrating and burdensome to both coders and providers, physicians should be encouraged to provide clear documentation at the point of care.
Charlene Thiry, RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Phone: 913-796-5944
charlene.thiry@TrustHCS.com
www.TrustHCS.com
Read our blog: http://www.trusthcs.com/blog/
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-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, January 22, 2016 7:53 AM
To: Charlene Thiry
Subject: RE: [cdi_talk] Debridement
I have never heard this before.
Julie Monty
RN, CCDS
HIM Dept.
(518) 314-3476
JMonty@cvph.org
The University of Vermont Health Network Champlain Valley Physicians Hospital UVMHealth.org/CVPH
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, January 22, 2016 8:52 AM
To: Julie A Monty
Subject: RE: [cdi_talk] Debridement
No.
Syndi Hudson, RN, CCDS,CCM
CHRISTUS Santa Rosa New Braunfels
CDI Specialist
cynthia.hudson@christushealth.org
830-643-6116 (Office)
830-643-5139 (Fax)
“We are His hands”. Isaiah 64:8
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, January 22, 2016 7:39 AM
To: Hudson, Cynthia
Subject: [cdi_talk] Debridement
One of our coder told us we had to have pathology(biopsy) to code excisional debridement. Is this right?
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>
Paul Evans
Sent from iPad2
I think so, but don't you need to know the instrument used?
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity