Context matters with excisional debridement

By Glenn Krauss,BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI

Excisional debridement procedures in the inpatient setting remain under intense scrutiny by Recovery Auditors, Medicare Administrative Contractors (MAC), CERT contractors, and other third-party payers given the high error rate associated with the ICD-9-CM Volume 3 procedure coding.

CMS highlighted this high error rate in the Volume 1, Issue 2 February 2011 Medicare Quarterly Provider Compliance Newsletter under Recovery Auditor Finding; Excisional Debridement—Incorrect Coding.

Recovery Auditors found that hospitals incorrectly reported excisional debridement when the provider debrided the wound using autolytic, enzymatic, or mechanical (whirlpool) debridement. They should have reported non-excisional debridement. The Recovery Auditors focused on whether the physician’s documentation explicitly supported the assignment of excisional debridement (ICD-9-CM code 86.22) within a specific range of MS-DRGs as follows:

• 463, wound debridement and skin graft except hand for musculoskeletal connective tissue disease with MCC  
• 464, wound debridement and skin graft except hand for musculoskeletal connective tissue disease with CC
• 465, wound debridement and skin graft except hand for musculoskeletal connective tissue disease without CC/MCC  
• 573, skin graft and or debridement for skin ulcer or cellulitis with MCC
• 574, skin graft and or debridement for skin ulcer or cellulitis with CC
• 575, skin graft and or debridement for skin ulcer or cellulitis without CC/MCC
• 901, wound debridement for injuries with MCC
• 902, wound debridement for injuries with CC
• 903, wound debridement for injuries without CC/MCC

Continued scrutiny on debridement

Auditors continue to focus on inpatient debridement procedure coding because of ongoing challenges with physician documentation. In addition, Coding Clinic has published multiple references and guidance to clarify the appropriateness of assigning the excisional debridement codes.

Clinical documentation improvement (CDI) specialists make coders second-guess code assignment when they seek clarification of documentation of “excision,” or “sharp debridement” to optimize the MS-DRG and improve the case mix index. Excisional debridement is considered a surgical procedure that directly impacts the MS-DRG mapping.

Medicare contractors and other third-party payers aim to identify “inappropriate” excisional debridement code assignment and thereby reduce reimbursement outlays in the present-day healthcare cost containment environment.

Addressing clinical documentation deficiencies
Addressing clinical documentation deficiencies associated with debridement procedures by clarifying “excisional” versus “non-excisional” overlooks the underlying premise of adherence to best practice standards of clinical documentation. Following these standards in wound care requires the provider to document a complete and accurate account of the wound that incorporates:

• History of present illness of the wound
• Any previous treatments of the wound and their success or failure
• Any modifying factors or complications/comorbid conditions that will potentially impact the healing and management of the patient’s wound
• Any diagnostic tests planned, such as MRIs, vascular run-offs of the leg(s), bone scans
• Any planned consultations to address peripheral vascular disease or antibiotic management
• Complete description and account of the wound 
• Documentation of the physician’s clinical judgment, medical decision making, and thought processes supporting the decision to perform the debridement as part of an organized plan of care for the wound

Focusing on the context of the wound and the best practice standards of clinical documentation associated with debridement procedures, as well as descriptive terminology of the actual procedure performed, will resolve the quandary of deciding between excisional versus non-excisional debridement. CDI specialists should not focus only on documentation that strictly impacts the hospital and bears little relevance to the physician’s own practice and business of medicine. Instead, develop a compelling argument for the physician to consider in his or her consistent practice of wound care debridement documentation.

Physician debridement documentation requirements
MACs spell out physician documentation requirements in Local Coverage Determinations (LCD). MACs create LCDs for services they have identified as problematic from a documentation and reimbursement standpoint. LCDs are created for services MACs consider:

• Overused/over-ordered
• Not documented sufficiently/inadequately documented
• Misused
• Medically unnecessary

Let’s take a look at an LCD for debridement of wounds from Palmetto GBA, the MAC for North Carolina, South Carolina, West Virginia, and Virginia.

LCDs typically consists of the following components:

• General background or abstract
• Coverage guidance; limitations of coverage
• CPT® codes that the LCD covers
• ICD-9-CM codes that support medical necessity
• Documentation requirements

CDIs should become more familiar with an LCD governing debridement procedures, provide guidance, and share knowledge of the necessary documentation requirements for debridement of wounds. This allows us to help physicians improve documentation and meet medical necessity and reimbursement requirements from both a physician and hospital perspective.

Consider the following information from the Palmetto GBA LCD referenced earlier when talking with physicians about appropriate and proper documentation of wound care debridement procedures.

For the purpose of reimbursement, CMS defines a debridement as the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. The Palmetto GBA LCD applies to debridement of localized areas, such as wounds and ulcers. It does not apply to the removal of extensive eczematous or infected skin. Debridement is indicated whenever necrotic tissue is present on an open wound or in cases of abnormal wound healing or repair. Debridement techniques usually progress from non-selective to selective to surgical, but can be combined. Palmettos will not consider debridement reasonable and necessary for a wound that is clean and free of necrotic tissue.

Debridement is used in the management and treatment of wounds or ulcers of the skin and underlying tissue. Providers should select a debridement method most appropriate to the type of wound, the amount of devitalized tissue, the condition of the patient, the setting, and the provider’s experience.

Another point to consider is whether the physician documented and described the wound to the extent the diagnosis is considered medically necessary and reimbursable by Medicare. Keep in mind that the existence of a “covered diagnosis” does not assure payment for the debridement procedure. Providers must document diagnostic statements supported by clinical facts of the case to ensure reimbursement under the provisions of medical necessity and reasonable and necessary services.

CMS does not consider the following services to be debridement:

• Washing bacterial or fungal debris from lesions
• Removal of secretions and coagulation serum from normal skin surrounding an ulcer
• Dressing of small or superficial lesions
• Trimming of callous or fibrinous material from the margin of an ulcer
• Paring or cutting of corns or non-plantar calluses
• Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement.

In addition, skin breakdown under a dorsal corn that begins to heal when the corn is removed and shoe pressure eliminated is not considered an ulcer and does not require debridement unless there is extension into the subcutaneous tissue.

If the physician performs these services and describes debridement, talk with the physician about what CMS or a third-party payer considers to be debridement and what the provider must document. Lastly, providers must document an accurate and complete descriptive picture of the debridement performed, including instruments and methodology employed. The Palmetto LCD governs debridement of subcutaneous tissue, muscle or fascia, bone, as well as sharp selective and non-selective debridement. The provider’s documentation must include at a minimum:

• Current wound volume (surface dimensions and depth)
• Presence (and extent of) or absence of obvious signs of infection
• Presence (and extent of) or absence of necrotic, devitalized, or non-viable tissue
• Other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown

The operative report for debridement procedures must demonstrate:

• Tissue removal (i.e., skin, full or partial thickness; subcutaneous tissue; muscle and/or bone)
• Character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement
• Whether the provider removed any viable tissue

Excisional versus non-excisional debridement
The traditional approach to clarifying whether the debridement constitutes excisional and non-excisional through repetitive queries and clinical documentation tip sheets will do little to change overall physician behavior patterns.

Instead, capitalize on the opportunity to educate yourselves and your physicians on the requisite elements of documentation outlined in your MAC’s LCD wound debridement LCD.

Only then will we be successful in altering physician and avoiding the episodic and transactional approach to addressing excisional versus non-excisional debridement documentation.

Editor’s note: Glenn Krauss,BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, is Executive Director of the Foundation for Physician Documentation Integrity with Accretive Health in Chicago. This article originally published on www.JustCoding.com.