To say debridement documentation is challenging is an understatement. It must be descriptive enough to create a clear picture of the procedure performed, a requisite level of detail that is tricky to attain because the procedure title and description within the operative note often do not correlate.
Correct debridement documentation will include the following five elements, which provide the level of detail a medical coder needs to assign the appropriate debridement code:
- Wound, burn, or infection site.
- Depth of tissue being debrided
- Instrument used
- Removal of devitalized or necrotized tissue
- Mechanism of debridement
Without specific and detailed documentation, coders will struggle to accurately determine the type of debridement performed, device used, and/or the tissue depth—all of which can impact reimbursement and compliance and contribute to the already high rate of claims denials related to wound care services.
In fact, documentation issues are the culprit behind most denial or partial denial of debridement claims. Typically, documentation fails to support medical necessity, or it lacks a valid plan of care, method of debridement, and/or description of the wounds and treatment effectiveness. Another common cause is documentation that fails to support the service billed.
Another challenge medical coders face when reporting debridement in ICD-10-PCS is differentiating between the root operations: excision vs. extraction. Other documentation elements coders must consider include diagnosis (i.e., wound type); anatomic location; depth of the debridement; method used to debride; and type of tissue that was removed (e.g., skin, muscle, bone, tendon).
Unclear documentation on any of these elements should result in a provider query to obtain the missing detail. Otherwise, the risk is high that the debridement claim will be over- or undercoded, both of which can significantly impact reimbursement and compliance.
Illustrating the Complexity: Excisional vs Non-Excisional
An excellent illustration of the complexity and costs involved with ensuring appropriate codes are used and documentation is sufficiently supportive is coding of excisional or non-excisional debridement. When a facility’s inpatient care is incorrectly coded as excisional instead of non-excisional debridement, in some MS-DRG scenarios it can result in an overpayment of $18,398.22.
- Excisional debridement: A sharp instrument like a scalpel is used to remove devitalized tissue. It is typically classified to the root operation of "excision" in the Procedure Coding System (PCS).
- Non-excisional debridement: the nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis, slough, or foreign material. It is classified to the root operation of "extraction."
The code for excisional debridement is assigned when the physician specifically documents "excisional debridement" or clearly documents "removal of tissue by excision." The specific type of instrument used, e.g. Versajet for hydrosurgical debridement, should also be documented to assist in the description and help verify the type of debridement.
The method of debridement must also be clearly stated in the description and the operative note must support that description. For example, it is insufficient to document just “debridement with a sharp instrument” because while scissors may be used to cut a loose fragment, doing so is not indicative of excisional debridement.
Excisional debridement documentation should also specify the depth of the tissue debrided. When making that determination, it helps to remember that:
- The outermost layer of skin is the epidermis
- Subcutaneous tissues can include the superficial fascia and subcutaneous fat, nerves, arteries, and veins
- Fascia/deep fascia involves the area between the subcutaneous tissue and muscle
- Muscle lies beneath the fascial layer
- Bone is the deepest layer that can be debrided
If fascia is debrided, documentation should specify whether it is superficial fascia. If bone debridement is performed, it may involve removing skin and bone close to, or surrounded by, the infected wound area. Debridement of eschar, the dry, dead tissue within the wound that is commonly seen with pressure ulcers, may also be noted.
When both excisional and non-excisional debridement are performed at the same site, only the excisional debridement code would be coded, and the excision is the definitive treatment at the site. The coder—not physician—is ultimately responsible for reading the provided documentation to determine the root operation it equates to in PCS definitions.
Finally, if root operations such as Excision, Extraction, Repair or Inspection are performed on overlapping layers of the musculoskeletal system (B3.5), the body part specifying the deepest layer is coded. In the case of an excision or resection of a body part followed by a replacement procedure (B3.18), code both procedures to identify each distinct objective, except when the excision or resection is considered integral and preparatory for the replacement procedure.
Accuracy is Imperative
There is a lot riding on the accuracy of debridement documentation and coding, so it is imperative that providers and coders work together to ensure documentation is complete, accurate, and fully supports the codes utilized. Doing so helps achieve the end goal of eliminating the risk from the high-risk game of debridement coding more effectively and efficiently. Contact us for assistance with medical coding, including high-risk areas like debridement coding and documentation, to optimize accuracy and reimbursement.
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