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3 Questions Can Heal Decubitus Ulcer Coding Sores

Published on Fri Jun 25, 2004

Poor documentation could cost providers up to $350 per patient.

Coders for physicians shouldn't get too accustomed to using excision codes for decubitus ulcer removals -- they may need to dig a little deeper in their CPT manual. In many cases, they'll need to know the location and depth of the wound, as well as whether the physician closed it. Coders should ask themselves these three key questions:

Question 1: Did the Physician Close the Wound?

Answering this question will help narrow the code selection to either an excision or a debridement procedure.

If the physician closes the wound, report an excision (15920-15958). In this case, the physician will clear the wound of infection prior to closing. On occasion, she'll also need to remove underlying structures (generally a bony protuberance, such as the coccyx) at the same time.

If the physician leaves the wound open, though, report a debridement (11040-11044). The physician may choose to leave the wound open in the hopes that healthy tissue will grow over the site of the ulcer. This method may require that she perform subsequent debridements over time as the wound heals. Only if there are no signs of infection will the physician perform an excision and close the wound.

Decubitus ulcers can be any chronic ulcer of the skin, including bedsores, plaster ulcers, and pressure ulcers, says Mary Brown, CPC, CMA, coding specialist at OrthoWest PC in Omaha, NE. These wounds occur because of local interference with circulation, and usually appear over a bony prominence at the sacrum, hip (trochanter), heel, shoulder or elbow.

Question 2: For Excision, What's the Location and Closure Method? Choose an appropriate excision code according to the location of the ulcer. Here are the options:

  • Coccygeal -- 15920-15922
  • Sacral -- 15931-15937
  • Ischial -- 15940-15946
  • Trochanteric -- 15950-15958

    Note: For an unlisted location, another possible option is 15999 (Unlisted procedure, excision pressure ulcer). See CPT for a complete list of code definitions.

    In some cases, the above codes also describe removal of underlying bony structure (ostectomy), which may also become infected, says M. Trayser Dunaway, MD, a physician in private practice in Camden, SC. For example, 15931 describes excision of a sacral pressure ulcer, while 15933 describes the same procedure but with further removal of bone below the site of the ulcer.

    And closure type does matter: Choose between at least two codes to describe the type of closure the physician used for each ulcer location. The first code (for instance, 15920, Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture) describes closure by sutures, while the second code (for example, 15922, ... with flap closure) describes a closure using skin flaps.

    Question 3: How Deep Was the Debridement?

    When assigning debridement codes, coders need to know the depth of the tissue the physician removed. This information is crucial, because without supporting documentation, they can only report the most superficial debridement code (11040, Debridement; skin, partial thickness). But if the physician actually debrided all the way to muscle and bone (11044), and the coder only reports 11040, they could lose up to $350 in payment simply because the documentation wasn't sufficient.

    Documentation must-have: When debriding an ulcer, the physician should note not only the location of the ulcer but also the depth/layers of the debridement. Coders also can describe the appropriate depth of debridement using the following codes:

  • 11040 -- Debridement; skin, partial thickness
  • 11041 -- ... skin, full thickness
  • 11042 -- ... skin, and subcutaneous tissue
  • 11043 -- ... skin, subcutaneous tissue, and muscle
  • 11044 -- ... skin, subcutaneous tissue, muscle, and bone.

    Make sure the medical record is complete with this information.

    Tip: Report muscle and skin grafts separately. When the physician closes a sacral, ischial or trochanteric ulcer excision using muscle flaps or skin grafts, report a separate code to describe the closure, according to CPT guidelines.

    For example, suppose the physician 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 code 15734 (Muscle, myo-cutaneous, or fasciocutaneous flap; trunk).

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