General Surgery Coding Alert

"When a coccygeal decubitus ulcer is excised or debrided, the patients coccyx may also be removed to relieve pressure on the ulcer. Normally, this procedure is billed using either the debridement or decubitus ulcer excision codes. In some cases, however, neither the excision nor the debridement codes in the integumentary section of CPT most accurately describe the services performed, as in the following case study.

Note: For more information on debridement and decubitus ulcer excision codes, see General Surgery Coding Alert, March 2001.

Operative Report

Preoperative diagnosis: Coccygeal decubitus with gangrene and invasive infection.

Postoperative diagnosis: Same.

Procedure: Wide debridement of coccygeal decubitus with excision of coccyx and drains to the presacral space.

History: This 97-year-old man has been progressively worsening over the last six months and has not been eating well for the last two to three months. He has had a coccygeal decubitus and trochanteric decubitus. The coccygeal decubitus developed a foul odor and black discoloration over the last two to three days. He was brought to surgery for debridement.

Operative Findings: The patient has an approximately 10-cm x 10-cm area of necrosis with black discoloration and foul odor extending onto the fascia around the sacrum and coccyx. It appeared to tunnel anterior to the sacrum along the coccyx. The patient also shows some beginning black discoloration of the superficial muscle of the gluteus. [The discoloration] does not appear to go down around the rectum.

Operative procedure: With the patient in the left lateral decubitus position, partially on his stomach, the sacral area and buttocks were prepped and draped. The area circumferentially was infiltrated with Marcaine 0.5 percent with Epinephrine and Xylocaine 2 percent with Epinephrine mixed 50/50. The skin was then excised about 1 cm back from the edge with cutting current electrocautery. It became obvious that it was going back to skin subcutaneous tissue that was viable. He still has some black discoloration extending along the fascia of the gluteus muscle and bone. This was all debrided. Some undermining of the skin was left because it was widely drained. The coccyx was excised to allow draining of the presacral space. Although there was no necrotic tissue in the presacral space there was some turbid fluid and a cavity of 3 to 4 cm was identified and drained. Hemostasis was obtained with electrocautery and the wound observed for a couple of minutes. It was then packed with 2-inch Iodoform gauze and fluffs. An elastic dressing was placed around the lower abdomen and sacral area. The patient was then removed from the operating room and recovered in surgery prior to being transferred back to his room.

Use Musculoskeletal Code

In this case the [...]