Business Briefs: Excision and Debridement Dilemmas for Inpatient and Outpatient Providers: Interview of Donna J. Cartwright, MPA, RHIA, CCS, RAC

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  KATHLEEN SCHAUM (KS): Many hospital-owned outpatient wound care departments (HOPD) are staffed by wound care professionals who work both in the HOPD and in the acute care hospital. I often receive calls from the physical therapists and wound care nurses who are certified to debride wounds. They are confused because some hospital coders tell them that they are supposed to chart in the medical record that they perform excisional debridement when they debride wounds at the patient’s bedside or in the inpatient physical therapy department. Then when they work in the HOPD, they are told that the excisional debridement codes are not appropriate for physical therapists and nurses. Can you please explain ‘why’ theses wound care professionals are given different coding direction for the same type of debridement?

  DONNA CARTWRIGHT (DC): First, to determine what level of debridement wound care nurses and physical therapists are authorized to perform, several factors need to be considered:

  First, nurses and physical therapists are licensed by each state. The scope of practice for these individuals should be clearly outlined by their State Practice Act. For example, if the State Practice Act allows for surgical excisional debridement, then the practitioner is authorized to perform that type of procedure in that state. If the State Practice Act only permits selective and non-selective debridements to be performed by the physical therapist or wound care nurse, then he/she cannot surgically excise wounds. In other words, physical therapists and wound care nurses may not perform procedures outside of their scope of practice. If they do, they put their license at risk.

  Second, each inpatient facility has its own set of bylaws and credentialing which may determine the scope of practice of each practitioner within the hospital. Physical therapists and wound care nurses must check to see if the hospital bylaws permit them to perform surgical excisional debridement.

  Third, each payer may have coverage policies that delineate the type of practitioner that can perform certain services within their medical policies.

  Summary, physical therapists and wound care nurses should research their State Practice Act, the hospital bylaws, and payer policies regarding levels of debridement that they can perform.

  KS: What are the definitions of excisional debridement, selective debridement, and non-selective debridement?
  DC: Here is where the confusion begins for coders. The inpatient coding system has two ICD-9-CM debridement procedure codes while the outpatient coding system has eight CPT® codes in two different categories.

  The two ICD-9-CM procedure codes that are used by the hospital to represent debridement work performed for inpatients are:

  86.22 Excisional debridement of wound, infection, or burn (subtext – Removal by excision of: devitalized tissue, necrosis, and slough)
  86.28 Nonexcisional debridement of wound, infection, or burn (subtext – Debridement NOS, Maggot Therapy, and Removal of devitalized tissue, necrosis, and slough by such methods as: Brushing, Irrigation (under pressure), Scrubbing or Washing, Water scalpel (jet)

  The eight CPT® codes that are used by HOPDs to represent debridement work performed for outpatients with chronic wounds are:

  Excision - Debridement
    11040 Debridement; skin, partial thickness
    11041 Debridement; skin, full thickness
    11042 Debridement; skin, and subcutaneous tissue
    11043 Debridement; skin, subcutaneous tissue, and muscle
    11044 Debridement; skin, subcutaneous tissue, muscle, and bone

  Active Wound Care Management
    97597 Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg, high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), with or without topical applications(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters
    97598 Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg, high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), with or without topical applications(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area greater than 20 square centimeters
    97602 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session

  In the inpatient setting, code 86.22 is considered to be a valid operating room procedure. In fact, use of that code could potentially change an inpatient bill from a lower paying non-surgical case to a higher paying surgical care. That may be the reason why coders question physical therapists and wound care nurses about the debridement work that was actually performed.

  To assist these wound care professionals, I obtained permission from the American Hospital Association to share some questions and answers published in previous issues of the Coding Clinic™. These questions and answers help to describe the rules used for inpatient coding and to define how codes 86.22 and 86.28 should be used.

  NOTE: These older issues of Coding Clinic can be ordered directly from the American Hospital Association.

Coding Clinic™, Second Quarter 2004, pages 5-6

  Reprinted with permission of the American Hospital Association, copyright 2004

  Question: “In second Quarter 2000, Coding Clinic advised that code 86.22, Excisional Debridement of wound, infection, or burn, may be assigned when a surgical removal or cutting away of devitalized tissue, necrosis or slough is performed by a nurse, physical therapist, physician assistant or physician. However, now we would like to know whether a “sharp debridement” performed by a physical therapist should be coded as an “excisional debridement.” When the documentation indicates the physical therapist “debrided devitalized tissue using a sharp instrument,” what is the appropriate code assignment?

  Answer: “The use of a sharp instrument does not always indicate that an excisional debridement was performed. Unless the documentation describes sharp debridement as a definite cutting away of tissue and not the minor removal of loose fragments with scissors or scraping away tissue with a sharp instrument, assign code 86.28, Nonexcisional debridement of wound, infection or burn. Generally, the debridement performed by physical therapists is nonexcisional in nature. In excisional debridement a scalpel is used to remove devitalized tissue. It involves cutting outside or beyond the wound margin. Scraping away tissue is not considered excisional debridement. Whirlpool debridement is an example of nonsurgical mechanical debridement. This advice is consistent with Coding Clinic Third Quarter 1991.”

  PLEASE NOTE: Coding Clinic First Quarter 2008, page 3 further clarified that the clinical information published regarding excisional debridement and cutting outside of the wound margins was provided for informational purposes only and does not represent clinical criteria for use of the 86.22 code.

  The important points from this citation are:
    1. Use of a sharp instrument does not always mean an excision was performed.
    2. The debridement must be clearly defined as a cutting away of tissue, not removal of loose fragments.
    3. Generally, physical therapy debridements are non-excisional.
    4. Scraping is not excisional debridement.

  Question: “In the discharge summary the physician describes the patient’s debridement: ‘the patient underwent a digressive debridement by physical therapy of her sacral decubitus with pulse lavage and wet-to-dry dressing changes …’ Should this procedure be coded as an excisional debridement or a nonexcisional debridement?”

  Answer: “Assign code 86.28, Nonexcisional debridement of wound, infection, or burn, for the procedure performed. The pulse lavage digressive debridement is considered nonsurgical mechanical debridement. It does not involve cutting away or excising devitalized tissue. In pulsed lavage, an irrigating solution (or irrigant) is delivered under pressure along with suction. Pulsed lavage is used for the debridement of bone and tissue for wound cleansing in order to remove infectious agents and debris. This method of wound cleansing is also known as “mechanical lavage,” “pulsatile lavage,” “mechanical irrigation,” and “high-pressure irrigation.”

Coding Clinic™, Fourth Quarter 2004, pages 138-139

  Reprinted with permission of the American Hospital Association, copyright 2004

  Question: “According to Coding Clinic second Quarter 2000, page 9, it is appropriate to assign code 86.22, Excisional debridement of a wound, infection or burn, when a health care provider such as a physical therapist performs an excisional debridement. However, Coding Clinic has also advised that code assignment is only based on physician documentation. For coding purposes, when the physical therapist documents “excisional debridement” must the attending countersign or confirm the procedure in the medical record?”

  Answer: “The advice published in Coding Clinic, second Quarter 2000, page 9, is still valid. Code 86.22 should be assigned when a provider, such as a physical therapist documents “excisional debridement” in the health record. It is appropriate to assign a procedure code based on documentation by a non-physician professional when that professional provides the service. This may be the only evidence that the service was provided. Historically, infusions (i.e. codes 99.29, 99.20, etc.) when carried out by a nurse have been coded. This same advice applies for drugs that are ordered by the physician, then administered and documented in the record by a nurse. See Coding Clinic, First Quarter 1997, pages 3—4 and Fourth Quarter 1998, pages 85—86, for examples of intravenous infusions. Please note this only applies to procedure coding where there is documentation to substantiate the code. This advice does not apply to diagnosis coding.”

  Therefore, if a physical therapist or certified wound care nurse receives an order from a physician to debride an inpatient’s wound or an outpatient’s wound, that professional must follow the guidelines of their State Practice Act and the hospital bylaws to determine the level of debridement they can perform. Then that professional must document the actual work that was performed and must take caution not to use the term “excisional debridement”, if the wound was not actually excised. The inpatient coder must select the ICD-9-CM procedure code and the outpatient coder must select the CPT® code that best describes the work that was documented by the physical therapist and the wound care nurse. Under no circumstances should the code be selected to increase the rate of payment!

  KS: I am still a little confused! It appears that the Coding Clinic™ is instructing the physical therapist to code for excisional debridement when they did not perform that level of debridement.

  DC: The physical therapist and wound care nurse must document very clearly whether or not they actually excised or simply debrided. As discussed in a previous answer from Coding Clinic™, use of a sharp instrument does not necessarily mean that tissue was excised. In addition, excision requires an incision into tissue in order to “cut away” vs. removal of tissue. As a reminder, if a physical therapist and wound care nurse are not licensed to perform surgical excisional debridements, they cannot select the ICD-9-CM or the CPT® code for that procedure.

  KS: How can wound care professionals obtain the reference material about the ICD-9-CM procedure codes and the CPT® codes?

  DC: The Coding Clinic™ provides hospital inpatient coders with official coding advice and guidelines that are approved by four cooperating parties; the Centers for Medicare and Medicaid Services (CMS), the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), and the National Center for Health Statistics (NCS) for the ICD-9-CM coding system. This publication is available from the AHA Central Office™ on ICD-9-CM, and can be ordered by calling (800) 621-6902, or by going to their website at www.ahacentraloffice.org. You can also check with the coders in your facility to see if they have a copy of the publication that you may use as a reference.

  Outpatient coders use several resources that provide official coding advice and guidelines for the CPT® coding system: CPT® manual; CPT® Assistant; and CPT® Network, an internet-based database that allows AMA members and subscribers to quickly research commonly asked questions and clinical examples (vignettes). If the answer to a specific question cannot be found in the database, authorized users have the opportunity to submit an electronic inquiry using a standardized form that is transmitted directly to the staff of CPT® coding experts. These resources are available for purchase from the American Medical Association’s (AMA) website at www.ama-assn.org: You can also check with the coders in your facility; they may have copies of the publications that you may use as references.

  KS: It appears that the need for “excisional debridement” vs. “non-excisional debridement” determines who can perform the procedure. Can you provide some pointers to help wound care professionals correctly document the actual work that they performed and to select the correct code?

  DC: Yes, following are some points to remember when documenting and selecting debridement codes:
    •General Guidelines:
      •Documentation should include an assessment of the wound itself and the surrounding tissue, and the size of the area to be debrided.
      •Documentation should include the terminology of “selective debridement”, “non-selective debridement”, or “surgical excisional debridement”. If the documentation is not clear, providers should expect the coders to question them before the coder approves the final code.
      •Documentation should include what is used to debride the wound such as a waterjet, scalpel, forceps, scissors, enzymes, etc.

    •Excisional Debridement:
      •11040-11044 are considered to be surgical excisional debridements.
      •According to CPT Assistant October 2006, volume 16, Issue 10, page 2, under Key Definitions, debridement is defined as “the removal of loose, devitalized, necrotic and/or contaminated tissue, foreign bodies, and other debris in the wound”
      • Excision is defined as “the surgical procedure through the deep dermis or subcutaneous tissues to prepare a wound for immediate or later grafting.”

    •Selective and Non-Selective Debridement:
      •97597-97598, 97602 codes are not considered to be surgical excisional debridements.
      •Removal of slough and fibrin may/may not belong in codes 97597-97598, 97602. NOTE: Some payers may not consider this to be debridement at all and may only allow payment for a clinic visit.
      •97597-97598 include the use of whirlpool; therefore, whirlpool should not be billed separately.

  KS: What elements should be included when providers document debridement that they perform?

  DC: The key to identifying the appropriate debridement code is the documentation that is in the medical record. The clearer and more concise the description of the wound and debridement procedure is, the easier it will be for your coders to select the appropriate code.

  Remember to always document:
    • Method of debridement (Cutting tissue out vs. removal of devitalized tissue)
    • Depth of tissue removed: Remember: Code what you debride, not what you see!!!
    • Instruments used for debridement- (blunt scissors, scalpel, tweezers. Note: if scalpel used indicate cutting away vs. removal of tissue)
    • Exact site of debridement
    • Area of wound (in cm²)
    • Characteristics of the material removed (ie, skin and surrounding tissue, loose devitalized or necrotic tissue, granulation, etc.)

  In summary, it seems that most debridements performed by physical therapists and wound care nurses on inpatients would be coded to 86.28, non-excisional debridement of skin. Remember that these wound care professionals can only perform procedures within their scope of practice. In the HOPD, the debridements performed by physical therapists and wound care nurses would be coded to the 97597, 97598, or 97602 CPT® codes. If by chance these wound care professional were actually permitted to perform a surgical excisional debridement, it should be documented in the record as a cutting away, not a minor removal of devitalized tissue by scraping, brushing, or other non-surgical mechanical debridement. This area remains confusing to many, but hopefully we will soon see more clarification on these definitions from the CPT® Excision/Debridement Workgroup. I have also written an inquiry to the Coding Clinic to hopefully gain more clarity on the use of 86.22 and 86.28 by non-physician practitioners. I will keep you and the readers posted!

  Donna Cartwright, MPH, RHIA, CCS, RAC, is the Senior Director of Reimbursement Services for Integra Life Sciences Corporation. She can be reached for questions and consultations by calling (609) 936-2265 or through her email address: dcartwright@integra-ls.com.

  Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling (561) 964-2470 or through her email address: kathleendschaum@bellsouth.net.

Reference

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