General Surgery Coding Alert

Knowing wound depth and the closure method is crucial to choosing a correct code for decubitus ulcer treatment. Get the facts here, and avoid selecting a debridement code when a better-paying excision may apply.

If the physician closes the wound following treatment of a decubitus ulcer (also known as bedsores, pressure sores or pressure ulcers), you should report an excision code (15920-15958). Knowing this simple fact alone is all you-ll usually need to know to differentiate excisions from debridements (11040-11044).

Only if there are no signs of infection will the surgeon perform an excision and close the wound. Documentation of remaining infection (the surgeon will leave the wound open) should provide a clue that a debridement code is a better match than an excision code, says Kate Kibat, CPC, compliance educator at the University of Washington Physicians in Seattle.

You should select an appropriate excision code according to the treated ulcer's location:

- Coccygeal -- 15920-15922

- Sacral -- 15931-15937

- Ischial -- 15940-15946

- Trochanteric -- 15950-15958

- All other (unlisted) locations -- 15999, Unlisted procedure, excision pressure ulcer.

After you have narrowed your selection according to ulcer location, you must determine whether the operative note describes ostectomy at the excision site. Surgeons will perform ostectomy (removal of underlying bony structure) when the bone under the ulcer also becomes infected, says Stacey Radick, RHIT, CCS, of Opticode.

"The main indication you-re likely to see for ostectomy would be a diagnosis of pressure ulcer with osteomyelitis," Radick says.

A quick glance of the CPT code descriptors will reveal which codes include ostectomy. For instance, 15931 describes "excision of a sacral pressure ulcer with primary suture," while 15933 describes the same procedure but also "with ostectomy" to account for further bone removal below the ulcer site.

You must determine the precise type of closure the surgeon uses following ulcer excision, Radick says. Closure types include primary suture (e.g., 15920, Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture), skin flap (e.g., 15934, Excision, sacral pressure ulcer, with skin flap closure), and separate muscle/myocutaneous flap or skin graft (e.g., 15956, Excision, throchanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure).

Report muscle/skin grafts separately: Per CPT guidelines, when the surgeon closes a sacral, ischial or trochanteric ulcer excision using muscle flaps or skin grafts, you should report a separate code to describe the closure, Radick says.

"These procedures can be done either at the same time or as a staged procedure," Radick says. For staged repairs that occur during the excision's global period, you will want to be sure to append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the appropriate muscle or skin graft repair code.

Example: The surgeon excises an ischial pressure ulcer with ostectomy. She then closes the operative wound using muscle flap. Report the excision with 15946 (Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure). You would claim the muscle flap closure separately with 15734 (Muscle, myocutaneous, or fasciocutaneous flap; trunk), per CPT instructions.

For those flaps still attached to the donor site, however, such as the groin area to close an ischial pressure ulcer, you should include the flap in the appropriate "excision with skin flap" codes (for example, 15922, 15934-15935, 15944-15945, 15952-15953), Radick says.

If the surgeon leaves the wound open following pressure ulcer treatment, claim a debridement (11040-11044) rather than excision. The surgeon may choose to leave the wound open to remove necrotic material or even, for small wounds, to heal by secondary intention. The surgeon will probably perform a number of debridements over time as the wound heals (see below for details).

When assigning debridement codes, you must know the depth of the tissue the surgeon removed. The "levels" of debridement include the following:

- Skin partial thickness (11040)

- Full thickness (11041)

- Subcutaneous tissue (11042)

- Subcutaneous tissue and muscle (11043)

- Subcutaneous tissue, muscle and bone (11044).

Documentation pays: The reimbursement difference between a partial-thickness debridement and debridement to the level of muscle and bone is about $150. Ask your surgeon for details if the operative note is unclear on how deep the debridement goes.

If the debridement includes the bone (11044), the documentation must indicate, "Debridement was carried out through the fascia, muscle, down to and including the bone," Kibat says. "If there is no documentation to support the debridement of the bone, for instance, you must report the lesser code (11043)."

"In working with many different practice groups, I have found that providing education to the surgeons on documenting the level of debridement can really affect the revenue," Kibat says.

If the surgeon reports debridement to the level of muscle or deeper (11043 or 11044) and performs subsequent debridements within the initial surgery's global period, you must append modifier 58 to the subsequent debridement codes, Kibat says.

For example: The surgeon debrides a pressure sore above the coccyx, also removing muscle and bone to clear infection. You report 11044. Thirty days later (and thus within 11044's global period), the surgeon must perform a subcutaneous debridement to remove additional diseased tissue. You should report this procedure using 11042-58.

Pay attention: The global period for 11043 is 10 days, as opposed to 90 days for 11044.

Skip 58 for subsequent debridement following 11040-11042: Codes 11040-11042 include zero global days, so you need not append modifier 58 to any subsequent debridements following these procedures.

For example, if the surgeon performs a full-thickness debridement, followed 10 days later by a partial-thickness debridement, you would report the first procedure as 11041, and the second procedure as 11040 with no modifiers attached.