General Surgery Coding Alert

Don't miss CPT^® 2012 debridement equation.

With over 25 CPT® codes and nine ICD-9 codes to describe your surgeon's pressure-ulcer patient encounter, you could use a few hints to make sure you capture all the pay you deserve. Follow our four expert guidelines to make sure you choose the right codes -- every time.

1. Distinguish Excision vs. Debridement

Although CPT® provides 20 "pressure ulcer" codes (15920-15999), those aren't your only choices when your surgeon treats a decubitus ulcer.

The first bit of information you'll need to extract from your surgeon's op note is: Did she excise the ulcer and close the wound, or did she debride the ulcer and allow the wound to stay open to heal? The answer to that question will lead you to choose codes from one of the following groups:

• 15920-15999 -- Excision ... pressure ulcer ...
• 11042-+11047 -- Debridement ...

According to CPT® instruction, you may report 11042-+11047 for "chronic ulcers," among other conditions.

Closure is key: Both debridement and excision are ways to "remove" the ulcer and clear infection, so you'll need to look for documentation regarding the closure to help you choose the proper code. For example, the surgeon might document an ulcer removal by stating, "The skin was cut in an elliptical fashion around the lesion, and the excised lesion was sent to pathology," notes Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. But the code choice could depend on a statement such as, "The wound was packed open to drain and heal by secondary intention," (debridement) versus "The surgeon closed the wound with 4-0 sutures in a layered fashion," (excision).

2. Know the Ulcer Location

Although CPT® codes for pressure ulcer debridement don't rely on body site, the codes for excision do. You'll find distinct decubitus ulcer excision codes for the following locations:

• Coccygeal pressure ulcer (15920-15922)
• Sacral pressure ulcer (15931-15937)
• Ischial pressure ulcer (15940-15946)
• Trochanteric pressure ulcer (15950-15958).

Choosing the proper ICD-9 code for decubitus ulcer also requires knowing the ulcer's location, as follows:

• 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. Look for Debridement Depth, Size

According to CPT® instruction, you should report debridement codes 11042-+11047 "by depth of tissue that is removed and by surface area of the wound."

Observe depth: The codes describe the following three depths:

• Subcutaneous tissue (includes epidermis and dermis, if performed) -- 11042 and +11045
• Muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed) -- 11043 and +11046
• Bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed) -- 11044 and +11047

For a single wound, "report depth using the deepest level of tissue removed," according to CPT®.

Note: If the debridement involves only the epidermis and/or dermis, see 97597-+97598 (Debridement [e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application[s], wound assessment, use of a whirlpool, when performed and instruction[s] for ongoing care, per session, total wound[s] surface area;...).

Calculate area: Each of the preceding pairs of codes identifies the "first 20 sq. cm. or less" for the first code in the pair, and "each additional 20 sq. cm. or part thereof" for the add-on code from the pair.

"If the surgeon debrides multiple pressure ulcers in a single day, you'll need to add up the treated area for each depth, even if the areas are from different locations on the body" explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

"Sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths," states CPT® instruction. If the surgeon debrides multiple depths, add up the area for each depth, and use modifier 59 (Distinct procedural service) to report both codes.

4. Focus on Bony Excisions, Closure Type

When treating a pressure ulcer, the surgeon might excise bony prominences to discourage possible ulcer recurrence. If so, the bony excision will impact your code choice. You'll find different codes for pressure-ulcer treatment that includes an ostectomy for ulcers in the sacral, ischial, and trochanteric regions.

For instance: If the surgeon performs an ischiectomy during the excision of an ischial pressure ulcer and sutures the site, you should report 15941 (Excision, ischial pressure ulcer, with primary suture; with ostectomy [ischiectomy]).

Check closure: You'll also distinguish the codes in the 15920-15958 range based on closure. In the preceding example, if the surgeon performed the same procedure except with a skin flap closure instead of a suture, you would report 15945 (Excision, ischial pressure ulcer, with skin flap closure; with ostectomy) instead of 15941.

CPT provides distinct codes for pressure ulcer excision with primary suture versus other closure (flap or skin graft) for the coccygeal, sacral, ischial, and trochanteric regions.