November 9, 2015

The Hate Factor: Convention A. 11

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I have told you about some of my pet peeves before, and below is another. How many of you reading this article hate Convention A.11 when it comes to PCS guidelines? Come on and admit it: you are silently chuckling about it now!

What is A.11?

 

As it states:

“Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.”

If I were a practicing physician, I would say “yep, all for it; I don’t have to change or add anything to my current documentation.” However, I now live on the other side, where I start to mumble, “here was a perfect opportunity for CMS (the Centers for Medicare & Medicaid Services) to put the onus on the provider for documentation, but inexplicably shied away.”

The example cited by CMS: “When the physician documents ‘partial resection,’ the coder can independently correlate ‘partial resection’ to the root operation Excision without querying the physician for clarification.”

And just when you thought it was over: nope!

The above example given by CMS represents a very small percentage of what coding staffs will be faced with as we forge into ICD10-PCS, and therefore it does not address the myriad of problems that will be surfacing, forcing coders to query for documentation clarification.

Let us look at debridement first.

Debridement fits into two different root operations, depending on the method used: excision and extraction. 

If you look up debridement in the ICD-10 index, you will find:

Debridement

Excisional (see Excision)

Non-excisional (see Extraction)

The definitions from CMS are as follows:

Excision: Cutting out or off, without replacement, a portion of a body part

Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force

As you can see, not only does the debridement issue not go away with PCS, it can get worse, as coders can code excision or extraction on almost any body part. The following important elements need to be found in the medical record to support assignment of the correct code:
 
Condition requiring debridement (e.g., ulcer, fracture, etc.)

Site of the debridement (e.g., foot, sacrum, etc.)

Extent and depth of debridement (code to the deepest level or layer of tissue)

Method(s) used to remove tissue (e.g., a definite cutting away of tissue)

Specific type of tissue being removed (e.g., skin, subcutaneous, muscle, bone, or tendon)      

A cutting of tissue outside or beyond the wound margin

Laterality

Documentation citing “excisional debridement” is not enough to code excisional debridement. The AHA (American Hospital Association) Coding Clinic for ICD-9-CM has provided much guidance on when to code ICD-9 code 86.22, Excisional debridement of wound, infection, or burn. The information from 1988 to 2005 specified that the code applied to the surgical removal or cutting away rather than scrubbing, scraping, brushing, washing, or snipping away bits of tissue with scissors. Therefore, applying the guidance, one would be geared to reporting an excisional debridement when a portion of a body part is cut out or off using a sharp instrument, such as a scalpel, wire, scissors, a bone saw, electrocautery tip, or a sharp curette, provided that the documentation in the medical record also supported the procedure.

The other important thing to remember, which most forget, is that the Coding Clinic provided guidance in cutting tissue outside the wound margin. The first quarter 2004 Coding Clinic further defined excisional debridement to involve cutting outside or beyond the wound margin in removing devitalized tissue. Documentation should clearly indicate that the procedure involves cutting outside or beyond the wound margin. If in doubt, look for a specimen being sent to the lab.

If the physician documentation currently does not support excisional debridement in ICD-9-CM, it won’t support excisional debridement in ICD10-PCS. Sometimes the documentation will cite excisional debridement, but when you read it you find that the provider has performed an incision and drainage. The provider has cut open the cyst/tumor to let out fluid. In these instances, drainage (taking or letting out fluids and/or gases from a body part) would be the reported procedure. If, however, the provider documentation just notes that a wound was “debrided to normal bleeding tissue,” or if it is noted in the documentation that “bleeding was observed,” this may require a provider query for clarification. If the documentation indicates removal of "necrotic tissue," this will not help in assigning the correct code.

In the past, the AHA has clarified via example that if a single leg ulcer was debrided via excision and included the removal of skin, subcutaneous tissue, fascia, muscle, and even bone, the only code assigned would be the excision of lesion of the specific bone(s). In ICD-10, a guideline has been added: B3.5 (Overlapping body layers ). If the root operations Excision, Repair, or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded. Therefore, if an excisional debridement that includes skin and subcutaneous tissue and muscle is performed, when the guideline is applied, the deepest body part would be muscle. This guideline mirrors AHA guidance in coding to the deepest layer.

Example:

Excisional debridement of left trochanteric pressure ulcer, stage 4 to bone

0QB70ZZ Excision left upper femur, open approach

ICD-9-CM does not specify the approach, whereas ICD-10-PCS provides approach values for open, percutaneous endoscopic, or percutaneous.

Example:

Right foot ulcer involving only the skin

If a non-excisional debridement was done, the code would be: 0HDMXZZ Extraction of Right Foot Skin, External Approach.

And if an excisional debridement was done, the code would be: 0HBMXZZ Excision of Right Foot Skin, External Approach; Excisional debridement of skin, subcutaneous tissue, and muscle of buttocks. 0KBN3ZZ Excision of Right Hip Muscle, Percutaneous Approach.

Or (accounting for laterality): 0KBP3ZZ Excision of Left Hip Muscle, Percutaneous Approach.

Also remember that excisional debridement is not necessarily exclusive to the OR. It can be done at bedside, or in the emergency department. From a coding perspective, as to which one, excisional versus non-excisional, may apply? Think about the inpatient example in which a patient is found to have a decubitus ulcer requiring excisional debridement; this patient is likely to require a longer hospital stay than one who only needs a round of antibiotics and Silvadene with regular dressing changes.

What is the takeaway in all of this? It will be imperative to read that operative report and to actually see that the physician is using a sharp instrument and cutting away and removing something. If, on the other hand, the physician performs a non-excisional debridement, the root operation will be extraction. Report an extraction when the physician pulls or strips off the body part. I am visual, so I think vein stripping procedures when thinking of the root word. 

Never, ever rely solely on the title of the procedure that is being performed; read that entire operative report. Sometimes the title of the procedure will contradict what the physician actually did. Finally, remember that PCS does not do away with worrying about how to code for debridement; in fact it will only get more complicated, so let the query process begin. 

If you have any pet peeves, let us know and we will explore them together.

 

 

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Denise M. Nash, MD, CCS, CIM

Denise M. Nash, MD, CCS, CIM, serves as vice president of compliance and education for MiraMed Global Services and as such she handles all Compliance and Education needs including migration to ICD-10. She has more than 20 years experience in the healthcare industry. Dr. Nash has worked for CMS in hospital auditing and has expertise in negotiation and implementation of risk contracting for managed care plans. She has also worked with individuals as well as physician groups on utilization and PQRS management to improve financial performance for the risk-based contracts and value based purchasing (VPB) programs. Her past experience also included consulting for the Office of the Inspector General of New Hampshire in its Fraud and Abuse Division.

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