General Surgery Coding Alert

When reporting treatment for a decubitus ulcer (also called a pressure ulcer or bedsore), you should know the method of closure (if any), as well as the location and depth of the wound. With this information, choosing the correct code is easy.

Consider Closure First

If the physician closes the wound, you can be certain that she performed an excision (15920-15958), says Tray Dunaway, MD, FACS, CSP, CHCO, CHCC, a surgeon, speaker, physician and coding educator, and healthcare consultant in Camden, S.C. In this case, the surgeon will clear the wound of all infection before closing.

Additionally, underlying bony structures (such as a portion of the sacrum) may become infected as a result of the pressure ulcer, and the surgeon may remove these structures at the same time as the pressure ulcer excision in a procedure called an ostectomy. The surgeon may also perform ostectomy when the ulcer won't heal and excision of the underlying bone will keep the wound from rubbing. CPT provides dedicated codes to report pressure ulcer excision with ostectomy.

Finally, CPT distinguishes between the types of closure, which can include primary suture, skin flap closure, and muscle/myocutaneous flap or skin graft closure.

Consequently, you will choose an appropriate excision code according to the ulcer's location, whether the procedure includes ostectomy and the type of closure, as illustrated in the charts on page 87.

Note: For pressure ulcer excision in an unlisted location, you must choose 15999 (Unlisted procedure, excision pressure ulcer). Be sure to include full documentation describing the ulcer's location, whether excision included ostectomy and the type of closure (primary suture, skin flap, muscle flap, skin graft, etc.) the surgeon used.

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, according to CPT guidelines.

For example, the surgeon excises an ischial pressure ulcer with ostectomy. She then closes the operative wound using muscle flap. To report the excision, you should use 15946 (Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure). Per CPT instructions, you may report the muscle flap closure separately using 15734 (Muscle, myocutaneous, or fasciocutaneous flap; trunk).

Specifically, you can report muscle/skin graft codes in addition to excision codes 15936-15937, 15946, 15956 and 15958.

If the surgeon leaves the wound open, you will report a debridement (11040-11044) rather than an excision. The surgeon may choose to leave the wound open in anticipation that healthy tissue will grow over the ulcer site. This method may require the surgeon to perform "staged" debridements as the wound heals. Only if there are no signs of infection will the surgeon perform an excision and close the wound.

When assigning debridement codes, you must know the depth of the tissue the surgeon removed. This information is crucial because without supporting documentation, you can only report the most superficial debridement code (11040, Debridement; skin, partial thickness), says Linda Martien, CPC, CPC-H, coding specialist at National Healing Inc. in Boca Raton, Fla. If, in fact, the surgeon debrides all the way to muscle and bone (11044), but you only report 11040, you could lose about $150 in payment because of insufficient documentation.

Make sure the medical record is complete: When debriding an ulcer, the surgeon should note not only the ulcer's location but also the debridement's depth/layers (partial thickness, 11040; full thickness, 11041; subcutaneous, 11042; subcutaneous and muscle, 11043; or subcutaneous tissue, muscle and bone, 11044).

Caution: "Ulcers are also -leveled,- so it's important to distinguish between the level of the wound and the level of debridement," Martien adds. "Just because a wound or ulcer extends into the subcutaneous tissue doesn't mean the physician performed a subcutaneous debridement."

If the surgeon performs 11043 or 11044 and reports subsequent debridements within the initial surgery's global period, you must append modifier 58 (Staged or related service by the same physician during the postoperative period) to the subsequent debridement codes, Martien says.

Example: The surgeon debrides a pressure sore above the coccyx, also removing muscle and bone to clear infection. You report 11044.

Nine days later -- 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.

Some payers differ: "Although using 58 during the global is correct coding from a CPT standpoint, it has been my experience that some payers will not accept the staged modifier with these debridement codes," Martien says. "You may wish to check with your individual payers about this."

Don't worry about 58 for 11040-11042: Because 11040-11042 include zero global days, you need not append modifier 58 to any subsequent debridements following these procedures.

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