Dermatology Coding Alert

Hint: Know depth and location

When your dermatologist performs a decubitus ulcer excision or debridement, you'll have to select from about 25 possible codes. If you ask yourself the following four questions about the excision and debridement services, you'll have an easier time choosing the right code, coding experts say.

In some cases the dermatologist may debride the ulcer and allow the wound to stay open to heal. Alternatively, the dermatologist may excise the ulcer, clear all infection and close the wound.

The difference: You should not distinguish debridement from excision by the ulcer's removal but, rather, by what the documentation specifies, says Deborah Ovall, CMA, CCS, CIC, lead coder and data quality analyst at the Medical College Hospitals of Ohio in Toledo.

For example, she says, documentation for an ulcer removal may read: "The skin was cut in a circular fashion around the lesion, and the dermatologist excised and sent the lesion to pathology. The dermatologist closed the wound with #4 sutures in a layered fashion (or packed open to drain and heal by secondary intention)." It is hard to tell the difference sometimes (both methods are ways of clearing infection), so you should always determine your coding on what the dermatologist describes in the documentation, Ovall says.

With the nine new ICD-9 codes for decubitus ulcers (707.00-707.09), you have more codes to choose from, specific to the ulcer's location on the body.

You can report debridement (11040-11044) based on three different skin levels -- partial thickness, full thickness or subcutaneous -- or as deep as muscle or even bone. For example, 11044 (Debridement; skin, subcutaneous tissue, muscle, and bone) describes a debridement that involves chipping off pieces of diseased bone to help rid the wound of infection.

In some instances, with coccygeal pressure sores the dermatologist may remove the coccyx to eliminate irritation and prevent the ulcer from recurring. The dermatologist may also excise bony prominences at the same time as a pressure sore.

Another example: If the dermatologist performs an ostectomy (specifically, an ischiectomy) during the excision of an ischial pressure ulcer, you should report 15941 (Excision, ischial pressure ulcer, with primary suture; with ostectomy [ischiectomy]) if the wound was then closed with primary suture. If the dermatologist closes the excision with flaps, report code 15945 (Excision, ischial pressure ulcer, with skin flap closure; with ostectomy).

If the dermatologist does not perform an ostectomy, you should report codes 15940 (Excision, ischial pressure ulcer, with primary suture) or 15944 (Excision, ischial pressure ulcer, with skin flap closure), depending on documentation and whether the dermatologist performed excision with primary suture (15940) or with skin flap closure (15944).

Note: As always, your ability to answer these questions depends largely on the quality and specificity of documentation in the operative report.