Orthopedic Coding Alert

Question: Our surgeon saw a patient status post hip replacement and he debrided two sites with infected decubiti. Should I report each site separately? Which code(s) should I report for this service?

Idaho Subscriber

Answer: As a first choice, you should look at the excision of decubiti codes (15920-15999). You should select a code according to the location of the ulcer(s) and whether the surgeon also performed ostectomy (bone removal) or primary suture. You may report each excision separately, and you can also report free skin grafts (15000-15261) if the orthopedic surgeon uses a graft to close the wound or donor site. This, however, will probably be rare.

For example, the surgeon removes both a coccygeal pressure ulcer and a sacral pressure ulcer with ostectomy. Report 15920 (Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture) and 15935 (Excision, sacral pressure ulcer, with skin flap closure; with ostectomy).

In addition, the orthopedic surgeon uses a fullthickness 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 surgeon's documentation will support a code from 15920-15999, you could instead select a code from 11040-11044, such as 11040 (Debridement; skin, partial thickness).