Monday, July 23, 2012

Code for the Day: Mondays and Debridement

Happy Monday!  Sorry if you find the statement annoying or offensive.  I am actually not a fan of Mondays.  As my Tinkerbell coffee mug reminds me, "Mornings are not magical" - and neither are Mondays.  This is why the Tinkerbell mug is my Monday choice for guzzling (partially caffeinated) coffee.  I try not to fall into the misery that many do on Mondays, though, because I don't want to set a negative tone for the week.  But I got a double whammy today.  Not only is it Monday, I had an email from a client this morning asking me a question about coding debridement.

Deep sigh.  Sip some coffee.  Get ready for the long email explanation back.

If you've coded at all recently, you know that debridement codes are under scrutiny by Medicare's recovery audit contractors (RAC) because of the vast payment differences between nonexcisional and excisional debridement.  And as I dusted off what has become my typical response to the documentation requirements for coding excisional debridement, this morning I found myself doing additional research.  And it reminded me of what is often the next question when I give advice for coding debridement in ICD-9-CM: will this be fixed with ICD-10-PCS?  Well, in a word, no.  As a matter of fact, it's going to be worse.

Sorry to add more bad vibes to your Monday.  Go grab another cup of joe and we'll talk about it.  Go ahead.  I'll wait....

Here's the deal.  In ICD-10-PCS - which, by the way, is completely different than coding in ICD-9-CM - we code according to root operations.  Debridement fits into two different root operations, depending on the method used: excision and extraction.  Here are the definitions of these root operations - straight from the ICD-10-PCS code set:
  • Excision - Cutting out or off, without replacement, a portion of a body part
  • Extraction - Pulling or stripping out or off all or a portion of a body part by the use of force
As you can see, excision involves cutting.  With a sharp instrument.  Like a scalpel.  So logic dictates that an excisional debridement would code to excision.  Easy peasy!

As far as extraction is concerned - first of all, ouch.  Lots of interesting things fall under extraction, like cesarean section, dilation and curettage, and of course, nonexcisional debridement.  Nonexcisional debridement can be performed using various methods, such as using enzymes, ultrasound, or simply sloughing off the tissue with gauze.

As you can see, not only does the debridement issue not go away with PCS, it has the potential to get a lot worse.  We can code excision or extraction or almost any body part.  So we still need to know these important elements in order to properly code:
  • Condition requiring debridement (e.g., ulcer, fracture)
  • Location of the debridement (e.g., foot, sacrum)
  • Depth of debridement (we code to the deepest layer)
  • Method(s) used to remove tissue (e.g., cutting away of tissue)
  • Specific tissue removed (e.g., skin, muscle) - the removal of "necrotic tissue" doesn't help us for coding purposes!
  • Instruments used to remove tissue (e.g., scalpel, scissors) 
To make it even more interesting, there is no default here like there is in ICD-9-CM.  So tell your doctors they need to be specific or we will be querying even more than we do now!

Want to see what this might look like?  Here's an example of a patient presenting with a right foot ulcer involving only the skin (note that the ICD-10-CM code specifies depth of ulcer involvement too).  A couple of disclaimers here - the reimbursement information is estimated based on the current MS-DRG grouper version 29.0 and the hospital base rate is fictional - I just wanted to give you an idea of the payment differences between excisional and nonexcisional debridement.  Also, the only codes I grouped are the ones you see here.
I don't want you to get hung up on the money here, other than to realize the potential compliance issues this presents.

Don't you feel so much more equipped to handle your Monday now?  See you Tuesday!