Health Information Management

Q&A: Coding for surgical debridement of devitalized tissue with scalpel

HIM-HIPAA Insider, November 8, 2011

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Q: One of our podiatrists documents “surgical debridement of devitalized tissue with scalpel” in his inpatient progress notes. I explained that he must clarify the technique, appearance, and size of the wound, and the depth of the debridement. He agreed to document these details but resists documenting the term “excisional.”

The podiatrist says he and his peers have omitted this term for years and that it isn’t required. He considers surgical debridement a more accurate term because the procedure involved cutting and the patient went to the OR. I explained that ICD-9-CM categorizes debridement as either excisional (ICD-9-CM procedure code 86.22) or non-excisional (ICD-9-CM procedure code 86.28). I explained that the procedure would default to the lesser-weighted DRG without documentation of the term excisional.
 
What should I do? I have shared relevant Coding Clinic issues to no avail. I couldn’t find any medical or podiatry literature that addresses documentation of surgical/sharp and excisional debridement.
 
A: The terminology used in ICD-9-CM procedures does not always align with clinical or surgical terms. Explain the difference between ICD-9 codes for hospital inpatients and the CPT® code description and language. The hospital and clinician use the same procedure codes and descriptions for outpatient services. However, codes and descriptions differ on the inpatient side.
 
Editor’s note: Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS, regional managing director of HIM, NCAL revenue cycle, Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, CA, answered the previous question in the November issue of Briefings on Coding Compliance Strategies.



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