Recent studies have documented inappropriate coding of debridement procedures The American Hospital Association has published extensive guidelines in Code , Excisional debridement, was defined as the “ surgical removal or. Procedure code assignment for excisional debridement has always been a in nature, and if the documentation truly supports an excisional debridement. ICD PCS Official Guidelines for Coding and Reporting South Carolina received a visit from a surprise guest – meet Otis, HIA's very own Elf on a Shelf. All too often, an excisional debridement is coded when the procedure documentation meets the definition ICDPCS Official Coding Guidelines specifies.
If a cleaning was performed as part of an overall procedure, it may not be coded separately.Complete guide for Lesion Excision, repair and MOH,s MICROGRAPH
However, if a provider performs a true excisional debridement, it could require separate code assignment. Excisional debridement is considered a surgical procedure that results in a surgical MS-DRG and a higher relative weight, which translates into a higher reimbursement. Root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to scalpel, wire, scissors, bone saw, and electrocautery tip.
Elements that must be documented in the medical record to support an excisional debridement include: Technique used by the provider cutting, scrubbing, trimming Instruments used scissors, scalpel, pulse lavage, or curette Nature of the tissue removed slough or necrosis, devitalized tissue, or non-viable tissue Appearance and size of the wound fresh bleeding tissue or viable tissue Last but not least, the physician needs to document the depth of the debridement.
Coding Debridement Procedures
This makes remembering all the information needed for appropriate code assignment a little easier. Excisional debridements can be performed by nurses, therapists, physician assistants, or physicians, and must be documented as such by the person who performed the debridement.
An excisional debridement can be performed in many areas in a facility. The location of where the procedure is performed has no bearing on whether it is considered excisional or non-excisional. External auditors require explicit documentation to support an excisional debridement, so CDI professionals need to make sure they have all the proper documentation in the chart. The medical record must contain supporting documentation. For example, coders should look for details on the procedure, including instruments used, the extent and depth of the procedure, if there was a definite cutting away of tissue, and if the cutting of tissue was outside or beyond the wound margin.
There are gray areas that can be problematic.
Coding Debridement Procedures
Several issues of Coding Clinic provide further guidance: It is appropriate to assign a procedure code based on documentation by a nonphysician professional when that professional provides the service; this only applies to procedure coding where there is documentation to substantiate the code. A debridement carried out in conjunction with another procedure is often, but not always, included in the code for the procedure.
Index entries and inclusion notes provide guidance. For example, the code for debridement of soft tissue is found in index under excision, lesion, soft tissue Maintain a current collection of references. Maintain and continually update processes and procedures related to complete, accurate, and timely medical record documentation. Audit and monitor identified discharges related to assignment code Long-term care hospitals should review PEPPER data on a consistent basis and observe for trends related to the billing of Participate in coding roundtables and other educational opportunities to discuss issues regarding coding of