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.

1. Was the wound closed and, if so, by what method?

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 For example, notes Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas, documentation for an ulcer removal may read: "The skin was cut in a elliptical fashion around the lesion, and the dermatologist excised and sent the lesion to pathology. The dermatologist closed the wound with 4-0 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.

2. Where was the ulcer?

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

• 707.00 -- Pressure ulcer; unspecified site
• 707.01 -- ... elbow
• 707.02 -- ... upper back
• 707.03 -- ... lower back
• 707.04 -- ... hip
• 707.05 -- ... buttock
• 707.06 -- ... ankle
• 707.07 -- ... heel
• 707.09 -- ... other site.

3. How deep was the debridement?

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.

"A partial-thickness debridement includes the epidermis and part of the dermis, but some dermal cells are left," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPCP, COBGC, CCC, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program. The physician typically performs these procedures using a scalpel or scissors, depending on the situation, she says.

4. Was anything else excised besides the ulcer?

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).

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