General Surgery Coding Alert

As many as 25 codes can describe the excision or debridement of a decubitus ulcer. To select the appropriate code, general surgery coders must understand the difference between an excision and a debridement. In addition, the following questions must be answered:

(1) Was the wound closed and, if so, by what method?
(2) Where was the ulcer located?
(3) How deep was the debridement (if performed)?
(4) Was anything else excised besides the ulcer?

Note: The coders ability to answer these questions depends largely on the quality and specificity of documentation in the operative report.

Choosing Excision or Debridement

Decubitus ulcers (also known as bedsores, pressure sores and pressure ulcers) occur because of local interference with circulation, and usually appear over a bony prominence at the sacrum, hip (trochanter), heel, shoulder or elbow.

Typically, a general surgeon will treat decubitus ulcers when structures underlying the external lesion are affected. In some cases the surgeon may debride the ulcer effectively removing it and allow the wound to stay open to heal. Alternately, the surgeon may excise the ulcer, clear all infection and close the wound. Debridement is not differentiated from an excision by the ulcers removal but, rather, by the fact that the wound has been cleared of infection and closed.

According to M. Trayser Dunaway, MD, a general surgeon in Camden, S.C., if infection is present and the wound is left open to heal, a debridement code (11040-11044) should be used. If, however, the wound is free of infection and closed by either sutures or flaps (or, in some cases, preparation of the wound for closure at a later date), the pressure sore is considered excised and the appropriate code from the decubitus ulcer category (15920-15999) should be used. Surgeons will close a repair only if there is no longer any sign of infection, stresses Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill. An excision is performed only after the wound has healed. Thats when codes 15920-15999 come into play, she explains.

Selecting the Correct Excision Code

Excision codes describe four types of pressure ulcers (coccygeal, sacral, ischial and trochanteric) that are differentiated by location, with the exception of 15999 (unlisted procedure, excision pressure ulcer). In addition, at least two codes describe each type of pressure sore excision the first describes closure by primary suture, and a second designates closure with skin flaps. For example, if a sacral decubitus ulcer is excised and the repair is closed with sutures, 15931 (excision, sacral pressure ulcer, with primary suture) should be used. If a skin flap is used, 15934 (excision, sacral pressure ulcer, with flap closure) is appropriate.

Note: For complete definitions of the 19 decubitus ulcer excision codes, refer to the CPT 2001 manual.

Also, three of the four pressure ulcers all but the coccygeal are sometimes closed using muscle flaps or skin grafts. In these cases, the surgeon excises the ulcer and prepares the wound for the additional procedure, which may be billed separately. For example, if the surgeon excises a sacral pressure ulcer that requires a muscle flap, 15734 (muscle, myocutaneous, or fasciocutaneous flap; trunk) may be billed in addition to code 15936 (excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure). If a split skin graft is used to close the repair, however, 15100 (split graft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children [except 15050]) should be coded with 15936 instead.

Finally, the coder must determine whether the surgeon excised more than the decubitus ulcer. With coccygeal pressure sores, for instance, the coccyx is routinely removed to eliminate irritation and prevent the ulcer from recurring. Bony prominences may also be excised at the same time as a pressure sore. For example, if an ostectomy (specifically, an ischiectomy) is performed during the excision of an ischial pressure ulcer, 15941 (excision, ischial pressure ulcer, with primary suture; with ostectomy [ischiectomy]) would be used if the wound was then closed with primary suture. If the repair was closed with flaps, code 15945 (excision, ischial pressure ulcer, with flap closure; with ostectomy) should be used. If no ostectomy is performed, codes 15940 (excision, ischial pressure ulcer, with primary suture) and 15944 (excision, ischial pressure ulcer, with flap closure), respectively, should be used.

Note: Pressure sores excised from other areas (such as the heel) must be coded using unlisted code 15999, regardless of how the wound was closed and whether an ostectomy was also performed.

Determine Correct Code by Depth of Debridement

If the operative report does not indicate that the wound was closed (probably because infection is still present), the pressure sore has not been excised even though the ulcer was eliminated. Often, surgeons will debride a pressure sore several times before the final excision involving closure, Mueller says.

Debridement (11040-11044) may occur on three 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.

Therefore, Mueller says, surgeons must describe not only the size of the ulcer being debrided but also the depth/layers of the debridement. Codes 11040-11044 describe layers. Unless the layers are described in the procedure note [i.e., documentation is provided], the only code that should be billed is 11040 [debridement; skin, partial thickness], Mueller notes.

Use Modifier -58 for Multiple Debridements

If a wound is left open, subsequent debridements may be required to facilitate healing. Debridements performed during the global period of the primary procedure (including earlier debridements) must be coded with modifier -58 (staged or related service during the postoperative period) appended to the appropriate debridement code.

If the ulcer was initially debrided, subsequent debridements may not require modifiers, depending on whether the initial debridement includes a global surgery package. For example, 11040-11042 have zero global days, whereas 11043 (debridement; skin, subcutaneous tissue, and muscle) has a 10-day global period and 11044 (a much more extensive procedure, because bone is involved) has a 90-day global period.

Therefore, any subsequent debridement following an initial procedure coded 11040, 11041 (debridement; skin, full thickness) or 11042 (;... skin and subcutaneous tissue) would not require modifier -58 when submitted. If the original debridement is coded 11043, however, any subsequent debridement within 10 days of the original procedure requires modifier -58, as does any subsequent debridement performed up to 90 days after a 11044. If the debridement involves a return to the operating room (OR), however, the appropriate debridement code should be billed with modifier -78 (return to the operating room for a related procedure during the postoperative period) appended.

If the surgeon debrides devitalized tissue from a Medicare patient with a postoperative infection, the debridement should not be reported because Medicare considers such procedures a complication of the initial surgery, and therefore part of the global package (unless a return to the OR was required, as noted above). This restriction may not apply to private insurers, however, because many third-party payers interpret complications differently, says Jan Rasmussen, CPC, a general surgery coding and reimbursement specialist and president of Professional Coding Solutions in Eau Claire, Wis. According to CPT, she notes, only routine uncomplicated postoperative care is included in the global package, and private carriers do not consider complications to be routine or necessarily related to the primary procedure. In such cases, carriers may follow specific guidelines about which modifier, if any, should be appended. Contact your local carrier for more information on how to submit such claims.

Mueller notes that these guidelines for coding and billing debridements apply to all open wounds, not only decubitus ulcers. Therefore, she says, physicians must document appropriately and communicate to the office all procedures performed in the hospital (whether at bedside or in the OR) during the postoperative period because many debridements are staged procedures and are not bundled into the global surgical package. The same reasoning applies to debridements performed in the office, which should be reported on the surgeons superbill or encounter form.

Avoid New Active Wound Care Codes

Two new active wound care management codes included in CPT 2001 (97601, removal of devitalized tissue from wound; selective debridement, without anesthesia [e.g., high pressure waterjet, sharp selective debridement with scissors, scalpel and tweezers], including topical application[s], wound assessment, and instruction[s] for ongoing care, per session; and 97602, ; non-selective debridement, without anesthesia [e.g., wet-to-moist dressings, enzymatic, abrasion], including topical application[s], wound assessment and instruction[s] for ongoing care, per session) were designed to report interventions associated with active wound care (i.e., debridements) as performed by licensed nonphysician practitioners (NPPs), such as physician assistants, nurse practitioners, clinical nurse specialists and physical therapists. Because the services described by the codes closely resemble debridement codes in the integumentary section of the CPT book, some physicians have incorrectly used 97601 in place of 11040.

Physicians should not use these codes. According to the AMAs CPT Changes 2001: An Insiders View, For wound debridement performed by providers other than nonphysician professionals, see 11040-11044. It also notes, 97601 and 97602 should not be reported in addition to codes 11040-11044.

Code 97602 is far less likely to be used erroneously because this code has not been assigned any relative value units by HCFA and will not be paid. Furthermore, private payers often follow Medicares lead on nonpayable codes, Mueller notes.

Finally, any debridements performed by an NPP in the same practice as a surgeon who performed an initial incision and drainage or more extensive debridement or excision of the ulcer would require modifier -58 to be appended to 97601.