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Address medical necessity, coding challenges related to wound care

JustCoding News: Inpatient, June 20, 2012

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Medical necessity denials traditionally focus on high-dollar MS-DRGs, such as those for hip and knee replacements; other MS-DRGs may also soon become targets.

Inpatient wound care frequently lacks sufficient documentation and could be one such service, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, CCDS, an independent HIM consultant in Madison, Wis.

"[Auditors] haven't gotten there yet, but I suspect they will," says Krauss. "Documentation lacks the clinical substance necessary to support medical necessity, and it doesn't capture a physician's clinical judgment and medical decision-making for performing the procedure. Doctors have been conditioned to document excisional debridement, but if you look at what they need for their own payment, they need to do a lot more than that."

Outpatient wound care documentation is often more detailed and thorough than its inpatient counterpart. Physicians providing these services often specialize in this area and are "more attuned to the business side," Krauss says. Outpatient wound care center documentation often includes dictated notes, pictures, documentation of failed conservative treatment, wound etiology notes, and information about patient compliance and the stability and interaction of active comorbidities. Hospitals often can't obtain this specificity, he says.

Local coverage determinations that focus on outpatient wound care documentation, such as that published by TrailBlazer Health Enterprises®, can be helpful on the inpatient side, he says. (Visit

"If we [used this information] on the inpatient side, everything would be golden," says Krauss. Some hospitals use TrailBlazer's information to develop inpatient wound care documentation templates for their physicians, he says. One copy is for the hospital; the other is the physician's for billing purposes.

Excisional or non-excisional?

Medicare Quarterly Compliance Newsletter, February 2011, Vol. 1, Issue 2, reminds coders to distinguish between excisional and non-excisional debridement.

The newsletter describes excisional debridement as the surgical removal or cutting away of devitalized tissue, necrosis, or slough. It notes that coders incorrectly report excisional debridement when physicians perform autolytic, enzymatic, or mechanical (whirlpool) debridement. Instead, they should report non-excisional debridement of wound, infection, or burn (86.28). Recovery Auditors have performed validation for these MS-DRGs:

  • 463-465 (Wound debridement and skin graft ¬except hand, for musculo-connective tissue disorders with MCC/CC, with CC, and without CC/MCC respectively)
  • 573-575 (Skin graft and/or debridement for skin ulcer or cellulitis with MCC, with CC, and without CC/MCC respectively)
  • 901-903 (Wound debridements for injuries with MCC, with CC, and without CC/MCC respectively)

Unfortunately, the terms excisional and non-excisional are specific to ICD-9-CM and may not be how physicians identify procedures, says Nelly Leon-Chisen, RHIA, director of coding and classification at the American Hospital Association in Chicago. Physicians must understand how ICD-9-CM terminology differs from their own clinical terminology, and also the risk of inaccurate coding, she says.

Coders, meanwhile, must realize that documentation of excisional debridement won't necessarily survive payer scrutiny, says Krauss. "Just because the magic word is in the chart doesn't mean that you're going to get paid," he says. "It's not just about getting the buzzword—it's about getting the support for the buzzword."

Providers often fail to documentation indications for a procedure (i.e., why debridement was necessary), says Krauss. When combined with a brief progress note indicating excisional debridement without complications, it can appear that services may not have been medically necessary. Payers seek documentation of clinical progression, advancement of wounds, and failure of previous conservative therapy as a primary basis for establishing medical necessity of debridements, he says.

Debridement of multiple layers

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 ICD-9-CM procedure code 83.45 (debridement of muscle, NOS)-not 86.22 (excisional debridement of wound, infection, or burn).

Debridement depth documentation challenges may continue, says Leon-Chisen. For example, "debridement down to the bone" could be interpreted as debridement that stopped short of taking bone tissue or that included 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 Krauss. Report debridement of separate sites independently and according to the deepest depth of the debridement performed at the specific site, he says.

Debridement with another procedure

Don't code minor debridement to clean a bone or debridement that is part of a larger procedure separately, says Leon-Chisen. For example, debridement is integral to arthroscopic shoulder repair, she says.

Coders often err when reporting incision and drainage (I&D) performed with debridement, says Krauss. Don't separately report debridement performed to ensure the effectiveness of I&D. However, coders should separately report debridement performed after I&D to address the presence of significant necrotic tissue around an area that was incised and drained, he says. Documentation must clearly describe the necrotic tissue and procedure performed. Coding Clinic, Second Quarter 2005, pp. 3-4, notes that debridement performed with another procedure is often, but not always, included in the procedure code. Refer to Coding Clinic, Third Quarter 2008, p. 8; Second Quarter 2006, pp. 23-24; and Second Quarter 1990, p. 27.

The challenges of new technology

New technology can be challenging; coders might not know whether debridement can be classified as excisional, says Leon-Chisen. For example, when physicians use the Qoustic Wound Therapy System®, report ICD-9-CM procedure code 86.28, in accordance with Coding Clinic, Second Quarter 2010, pp. 11-12. When they use ultrasonic-assisted curette and VersaJet™, report 86.28, in accordance with Coding Clinic, Third Quarter 2009, p. 13.

Wound care and the POA indicator

Coders are often too cautious when assigning a present on admission (POA) indicator for pressure ulcers, especially when the provider does not document the ulcer until several days after inpatient admission, says Krauss. If signs or symptoms are POA, coders can and should report an ulcer as POA. A query may be necessary without documentation of signs or symptoms.

Educate ED clinicians about the importance of documenting chronic conditions (e.g., chronic heel wounds) in addition to acute conditions that prompt patients to seek treatment, says Krauss. This facilitates accurate POA assignment and reduces queries, he explains.

Prepare for ICD-10

ICD-10-PCS distinguishes between excisional and non-excisional debridement. The ICD-10-PCS root operations excision and extraction denote excisional debridement and non-excisional debridement, respectively.

This doesn't mean that physicians must use the term extraction, but if documentation shows that the tissue was pulled or stripped away, rather than cut, the debridement is an extraction, says Leon-Chisen.
ICD-10 will require coders to capture laterality and more specific anatomic wound locations, says Krauss.

This article was originally published in the June issue of Briefings on Coding Compliance Strategies. Email your questions to Senior Managing Editor Andrea Kraynak, CPC, at

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