Orthopedic Coding Alert

Extent of debridement and location of the pressure are your main guide.

When reporting pressure sores, you may be left perplexed if your surgeon does an ostectomy or excisional debridement. The confusion may become worse if your surgeon uses a flap to close the defect. Below are some tactics to improve your reporting of pressure sore treatment.

Identify the Intent of Ostectomy

Your surgeon may do an ostectomy for reasons more than one. "Actually, you are treating the ulcer by relieving the part of the bone that is causing the ulcer and trying to prevent recurrence," says Bill Mallon, MD, former medical director, Triangle Orthopedic Associates, Durham, N.C. The ostectomy may be done to prepare the base for a muscle or skin flap. In this case, you report code 15937 (Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy) for sacral ulcer and code 15958 (Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy) for the trochanteric ulcer.

Going by the CPT® definition, if a muscle or myocutaneous flap or skin graft is planned, you will report the service as 15958. If no flap is planned, CPT® code 15951 is the correct service," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington.

Determine The Depth of Debridement

Check the clinical note to determine if your surgeon does debridement in the ulcer. In that case, you report 97597 (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; first 20 sq cm or less) or 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; each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure]).

Alternatively, you turn to 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) -- 11047 (Debridement, bone [includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed]; each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure]), depending upon the size and depth of the debridement. "Debridement of the ulcer that is not excisional in nature would be reported as 97597, 97598, or by use of the standard wound debridement codes based on the size and depth of the debridement," says Stumpf.

Look At the Flap Your Surgeon Is Using

Confirm the flap used for ulcer closure. Your surgeon may decide to do a flap reconstruction for the pressure sore, depending upon factors like the patient's general health and the risk of recurrence. You surgeon may select a flap based upon the location of the ulcer.

Before going in for any reconstruction, your surgeon will debride the wound. This debridement will be more extensive and radical. Your surgeon may do a radical bursectomy by placing a methylene blue --moistened sponge in the bursa and will then excise the pressure sore circumferentially, removing all granulation tissue including that from the wound base.

Your surgeon may excise the ulcer and then close it using a skin flap.Ddepending upon the location of the pressure sore, you report 15934 (Excision, sacral pressure ulcer, with skin flap closure), 15944 (Excision, ischial pressure ulcer, with skin flap closure), or 15952 (Excision, trochanteric pressure ulcer, with skin flap closure) for the pressure sores on the scarum, ischium, and femur trochanter, respectively.

Confirm if your surgeon is using a combined flap of muscle and skin to close the wound defect.

Example: You may read that your surgeon used the fasciocutaneous gluteal thigh rotation flap based on the inferior gluteal artery and raised superior to the gluteal crease to reconstruct the defect of the pressure ulcer located on the ischeal tuberosity. Alternatively, your surgeon may use inferior gluteus maximus myocutaneous flap, hamstring myocutaneous flap, biceps femoris myocutaneous flap, or tensor fascia lata (TFL) flap to repair the pressure ulcer. In this case, you report 15946 (Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure).

Similarly, for the pressure ulcers located on the sacrum or greater trochanter of the femur, you select from codes below for the myocutaneous flap reconstruction.

• 15936 (Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure)
• 15956 (Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure)

Note: For coccygeal sores, you report code 15922 (Excision, coccygeal pressure ulcer, with coccygectomy; with flap closure) when your surgeon does coccygectomy along with a flap closure, irrespective of the nature of the flap, be it skin flap or myocutaneous flap.

When your surgeon does an ostectomy along with the skin flap, you report code 15935 (Excision, sacral pressure ulcer, with skin flap closure; with ostectomy), 15945 (Excision, ischial pressure ulcer, with skin flap closure; with ostectomy), or 15953 (Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy) for the sacral, ischial, and trochanteric pressure sores, respectively.