Health Information Management

Audit wound debridement MS-DRGs before your RAC does

JustCoding News: Inpatient, March 31, 2010

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Coders don’t need a recovery audit contractor (RAC) audit to prove to them that reporting inpatient wound care is particularly challenging. The culprit is typically lack of documentation to support excisional versus nonexcisional debridement of a wound, infection, or burn. Important details include the following:

  • The site of the wound, burn, or infection
  • The type of instrument used to perform the debridement
  • The depth of the debridement

Excisional debridement (ICD-9-CM procedure code 86.22) refers to the surgical removal or cutting away of devitalized tissue, necrosis, or slough. A provider may perform the procedure in an operating room, emergency room, or at the patient’s bedside, depending on the availability of a surgical suite as well as the extent of the area to be debrided. Nurses, therapists, physician assistants, or physicians may perform excisional debridement; however, when nonphysician practitioners perform it, they must report code 86.22. (See the American Hospital Association (AHA) Coding Clinic, Fourth Quarter 2004, pp. 138–139 effective with discharges January 31, 2005.)

Nonexcisional debridement (ICD-9-CM procedure code 86.28) is the nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis, or slough. During this procedure, a provider snips tissue and then provides Hubbard tank therapy. The provider may also remove loose fragments from the wound with scissors. Physicians or nonphysician providers may perform nonexcisional debridement.

Debridement has been the subject of industry attention for quite some time, but RAC audits have brought the procedure even further into the spotlight, says Gloryanne Bryant, RHIA, RHIT, CCS, CCDS, regional managing director of HIM, northern California revenue cycle, at Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, CA. This is also a frequent topic in AHA’s Coding Clinic.

CMS reports in its [Fiscal Year] 2006 RAC Status Document that it has recouped $3.9 million in overpayments related to DRG 263 (Skin graft and/or debridement for skin ulcer or cellulitis). It also has recovered $13.9 million in overpayments related to DRG 217 (Wound debridement and skin graft, exc. hand for musculoskeletal and connective tissue disease).

More recently, RACs in the permanent program have begun looking at code 86.22 as part of their complex DRG validation audits. For example, Connolly Healthcare (the Region C RAC) has approved validation of MS-DRGs 901 (Wound debridements for injuries with MCC), 902 (Wound debridement for injuries with CC), and 903 (Wound debridements for injuries without CC or MCC). HealthDataInsights (the Region D RAC) also has included each of these three MS-DRGs in its list of more than 60 MS-DRGs eligible for validation.

Standard language posted on HealthDataInsight’s Web site for each of its DRG validation issues states in part:

DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary’s medical record.

Although these MS-DRGs aren’t currently subject to medical necessity reviews, Bryant says once RACs begin assessing for necessity, providers had better pay attention. Debridement may be one of many procedures performed during a hospital stay, and during a medical necessity review, the entire record is fair game, she explains. “Although a particular DRG, diagnosis, or procedure would trigger a RAC to look at a record, now the whole record is open to scrutiny,” she says.

Bryant suggests considering these tips when preparing for RAC audits related to inpatient wound care:

  • Don’t make assumptions. One common assumption is that physicians performed excisional debridement when they used scissors. This may not be the case, says Bryant. Physicians may have used the scissors simply to cut away the loose fragments. Similarly, a scalpel may or may not indicate excisional debridement.
  • Conduct proactive audits. Don’t wait for a RAC to knock on your door before you implement a compliance plan, says Bryant. Proactive audits should target cases in which patients underwent excisional debridement (86.22), because this is the surgical procedure that drives each MS-DRG currently under review. Select at least 100 cases if your volume is that significant, says Bryant. If your volume is fewer than 100 cases, audit them all, she adds. Ensure that documentation supports the code billed and meets Coding Clinic guidelines. Hospitals also should consider auditing cases from a diagnosis perspective using specific diagnoses that typically warrant some type of inpatient wound care. These diagnoses include cellulitis, burns, diabetic ulcers, postsurgical wounds, arterial wounds, and other wounds that resist healing.
  • Provide ongoing coder education. Review and share any requests for complex reviews related to inpatient wound care services, says Bryant. Use these requests as an educational tool during coder team meetings. “Even though you cannot and should not manipulate, change, or addend anything, it’s important to know if you’ve got problems so you can perform future audits and put a corrective action plan in place,” she says.

Know important Coding Clinic inpatient wound debridement references

Bryant advises coders to review the following references to ensure compliance.

Fourth quarter 2008

  • Excisional versus mechanical debridement

Third quarter 2008

  • Debridement associated with incision and drainage

First quarter 2008

  • Wound debridement of coccyx
  • Documentation guidelines for excisional debridement
  • Documentation of sharp debridement

Second quarter 2005

  • Excisional debridement of sites not listed in index

First quarter 2005

  • Debridement for amputation site infection and cellulitis

Second quarter 2004

  • Clarification regarding whether a sharp instrument indicates excisional debridement was performed

Second quarter 2004

  • How to report pulsed lavage digressive debridement

First quarter 2003

  • Outpatient observation for monitoring/dressing changes after MVA

Second quarter 2000

  • Clarification for reporting excisional wound debridement

Fourth quarter 2000

  • How to report escharotomy

Third quarter 1991

  • Guidelines for coding excisional versus nonexcisional debridement

Fourth quarter 198

  • Revised code assignment to differentiate between excisional and nonexcisional debridement

Editor’s note: This article was originally published in the March issue of Briefings on Coding Compliance Strategies. E-mail your questions to Contributing Editor Lisa Eramo, CPC, at

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