Health Information Management

Tip for coding debridement of multiple layers

HIM-HIPAA Insider, June 12, 2012

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Medicare Quarterly Provider Compliance Newsletter, ­October 2011, Vol. 2, Issue 1, reminds coders to assign a code only for the deepest layer of debridement when coding multiple-layer debridements of the same site.

The newsletter scenario involves a debridement including skin, subcutaneous tissue, and muscle. Assign 83.45 (debridement of muscle, NOS)-not 86.22 (excisional debridement of wound, infection, or burn).

Debridement depth documentation challenges may continue, says Nelly Leon-Chisen, RHIA, director of coding and classification at the AHA in Chicago. For example, "debridement down to the bone" could be interpreted as debridement stopped short of taking bone tissue or including the bone. Review documentation to determine the deepest layer debrided; seek clarification if necessary, she says.

The multiple-layer rule (i.e., code only the deepest layer debrided) applies solely to same-site debridement, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, CCDS, an independent HIM consultant in ­Madison, Wis. Report debridement of separate sites independently and according to the deepest depth of the debridement performed at the specific site, he says.

Note: For more tips, view the June issue of Briefings on Coding Compliance Strategies.



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