General Surgery Coding Alert

Question: If our physician debrides two sites with infected decubiti, should we report each site separately? Which code(s) should we report for this service?


Maine Subscriber

Answer: First look at the decubiti excision codes (15920-15999). Select a code according to the ulcers- location and whether the physician also performs ostectomy (bone removal) or primary suture.

You may report each excision separately, and you may also report free skin grafts (15000-15261) if the physician uses a graft to close the wound or donor site.

For example, the physician removes both a coccygeal pressure ulcer and a sacral pressure ulcer with ostectomy. Report 15920 and 15935. In addition, the physician uses a full-thickness graft to close the sacral pressure ulcer excision. Therefore, you may report, for instance, 15200 (Full-thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less).

If you don't think the physician's documentation will support a code from the 15920-15999 range, you could select 11000 (Debridement of extensive eczematous or infected skin; up to 10% of body surface).

In this case, you cannot code the sites separately because 11000's descriptor specifies a certain percentage of body surface. Rather, you should add the total surface area of the two sites together to get the appropriate percentage. Based on that total area, you would report 11000, and add-on code +11001 (... each additional 10% of the body surface [list separately in addition to code for primary procedure]) if the physician debrides a total area greater than 10 percent.

If the infected decubiti extend deeper than the skin or if debridement involves more than just skin, you might also report a code from the 11040-11044 series (Debridement; skin, partial/full thickness, subcutaneous tissue, muscle and bone).