Part B Insider (Multispecialty) Coding Alert

If every excision looks the same, it's time to ask questions

Physicians at Aurora Health Care were stuck in a documentation rut. When one of them excised a pressure ulcer, they would document every single one the same way. So every time, Aurora was billing just the pressure ulcer, with a primary suture and no complications.

Until coder Rhonda Gudell started asking questions. -You-re telling me that every single last one of these you-re doing exactly the same way?- she asked the doctors. Of course not, the doctors said. Each pressure ulcer excision procedure was different, and sometimes the doctor performed a flap closure or ostectomy.

Reality check: The doctors were missing out on $100 to $140 in extra reimbursement per procedure in many cases. That's how much more Medicare pays in relative value units (RVUs) if the pressure ulcer excision (15920-15958) involves a flap closure or ostectomy. -We went through the RVUs,- Gudell says, -and a light bulb went off.-

Because Aurora's doctors see a lot of nursing home patients, pressure ulcers are a frequent problem.

Now Gudell has taught the doctors at Milwaukee-based Aurora to document a flap closure carefully. The doctor -actually has to tell us where the flap is coming from--the groin or other donor site,- she notes. The doctor should also document whether the flap closure is covered with petroleum gauze.

Sometimes doctors have the opposite problem, notes Leslie Johnson, a Houston, TX, coding consultant. The surgeon may excise a pressure ulcer and mention a -flap- in the documentation. But this doesn't mean a -flap- as in reconstructive closure. It just means the doctor lifted the skin.

This language can confuse coders, Johnson warns. If the surgeon mentions a -flap- for every excision, then you may fail to bill properly for cases where the doctor actually did perform a proper reconstruction with a flap.

As for ostectomy, your doctor should be documenting how he or she removed the bone, says Gudell. And the documentation should describe that the pressure went all the way down into the bone.