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Wound Care Presentation

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Wound Care Documentation Issues

Wound Care Documentation Issues

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    Wound Care Presentation Wound Care Presentation Document Transcript

    • Wound Care Documentation Issues Tracey Goessel, M.D. CEO FairCode Associates 1
    • General Wound Issues We Will Discuss What is the Nature of the Wound? What is the Origin of the Wound? Was the Wound Present on Admission? What is the Treatment of the Wound? (Including everyone’s favorite: excisional debridement!) 2010 Intersect Healthcare, Inc. FairCode 2 2
    • Open Wounds -- Lacerations What is associated with the wound? Be certain to capture associated injuries Does the wound meet the definition of complicated? Delayed healing Delayed treatment Foreign body or Major Infection How was the wound treated? Dermabond coded as application of tissue adhesives Capture length of wound and layers closed 2010 Intersect Healthcare, Inc. FairCode 3 3
    • Decubitus (Pressure Ulcers) “A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.” The National Pressure Ulcer Advisory Panel (NPUAP) 2010 Intersect Healthcare, Inc. FairCode 4 4
    • Decubitus Ulcers: Describe Location and Stage! Stage I Stage II Persistent, focal Pressure ulcer with erythema abrasion, blister, partial thickness skin loss involving epidermis and/or dermis 2010 Intersect Healthcare, Inc. 5 FairCode 5
    • Decubitus Ulcers, Continued Stage III Stage IV Full thickness skin Necrosis of soft loss involving tissues through to damage or necrosis underlying muscle, of subcutaneous tendon or bone tissue 2010 Intersect Healthcare, Inc. 6 FairCode 6
    • Skin Ulcers: Describe Source Are they diabetic in origin or decubitus? origin, Toe ulcer: likely diabetic Heel ulcer: likely decubitus Coding Clinic, Third Quarter 1991, pages 7-8, "Conditions listed with a diagnosis of diabetes mellitus or in a diabetic patient are not necessarily complications of the diabetes. The condition should be coded as such only when the physician identifies it as a diabetic complication." Query, query, query! 2010 Intersect Healthcare, Inc. FairCode 7 7
    • Skin Ulcers: Describe Source Coding Clinic Second Quarter 1994 Clinic, 1994, Page: 17 “Do not assume a cause-and-effect relationship between diabetes and peripheral vascular disease if one is not stated by the physician. Therefore, physician Therefore category 250.7X, Diabetes with peripheral circulatory disorders, would not be used unless the physician so stated that the peripheral vascular disease was diabetic or due to diabetes. The conditions would be coded separately.” Query, query, query! 2010 Intersect Healthcare, Inc. FairCode 8 8
    • Skin Ulcers: Determine if POA! Coding Clinic, Third Quarter 2008, Pages: 20-21 “There is no required timeframe as to when a provider (per the definition of "provider" used in the Official Guidelines for Coding and Reporting) must identify or document a condition to be present on admission.” Query, query, query! Q ! 2010 Intersect Healthcare, Inc. FairCode 9 9
    • Wound Treatment: Excisional Debridement “Excisional debridement is the surgical removal or cutting away of devitalized tissue, necrosis, or slough. Depending on circumstances such as the patient's condition, availability of a surgical suite, or extent of area to be debrided, excisional debridement can be performed in the operating room, emergency room, or at the patient's bedside.” “The attending physician must document in the medical record that an excisional debridement was eco d e cisional deb idement as performed.” Coding Clinic, Fourth Quarter 1988 Page: 5 2010 Intersect Healthcare, Inc. FairCode 10 10
    • Wound Treatment: Non-Excisional Debridement “Nonexcisional debridement is the nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis, or slough. Nonexcisional debridement includes snipping of tissue followed by Hubbard tank therapy. Nonexcisional debridement may be performed by a nurse, therapist, or p y y , p , physician.” “The use of a sharp instrument does not always indicate that an excisional debridement was performed. Unless the documentation describes sharp debridement as a definite cutting away of tissue and not the minor removal of loose fragments with scissors or scraping away tissue with a sharp instrument, assign code 86.28, Nonexcisional debridement of wound, infection, or burn. Coding Clinic, Second Quarter 2004 Page: 5 2010 Intersect Healthcare, Inc. FairCode 11 11
    • Wound Treatment Oasis matrix burn Escharotomy no l h longer dressing excisional debridement of skin Code as application of is now re-indexed to code wound dressing 86.09, Other incision of skin and subcutaneous tissue. ti e 2010 Intersect Healthcare, Inc. 12 FairCode 12
    • Wound Treatment Maggots! “Assign code 86.28, Nonexcisional debridement of wound, infection or burn, for maggot therapy.” Coding Clinic, Second Quarter 2001 Page: 18 2010 Intersect Healthcare, Inc. FairCode 13 13
    • Sample Queries The medical record documentation requires clarification. The patient is documented in your progress notes to have pressure sores on the sacrum, identified as stage III in the nursing notes. Please provide clarification whether this problem was present on admission. 2010 Intersect Healthcare, Inc. FairCode 14 14
    • Sample Queries You noted on day 3 of admission that the patient’s ulcer was debrided. Could you please specify and clarify the nature of the debridement, including whether or not there was actual surgical removal of devitalized tissue, or merely a scraping away of necrotic tissue? 2010 Intersect Healthcare, Inc. FairCode 15 15
    • Sample Queries The patient, who is a diabetic, is noted to have lower extremity ulcers due to peripheral vascular disease. Please specify the relationship, if any, between the patient’s peripheral vascular disease and his diabetes. 2010 Intersect Healthcare, Inc. FairCode 16 16
    • Excisional Debridement Charmira Orr BS,LPN,CCS,CPC,CCDS, Director of Coding and Auditing Intersect Healthcare 1
    • Learning Objectives Participants will understand how to utilize the RAC demonstration area target on Excisional Debridement to perform internal audits Participants will review and understand highlights to include in audits when focusing on excisional debridement Participants will review and understand the ICD-9 CM guidelines for assigning 86.22 86 22 Excisional Debridement 2010 Intersect Healthcare, Inc. 2 2
    • The RAC Demonstration 86.22 86 22 Excisional Debridement #1 procedure code that was coded incorrectly Coding errors directly contributed to understanding g g guidelines, documentation , Two of the highest recoupment DRG’s for 86.22 were DRG 217 and DRG 263 collectively $17.8 million in 2006 2010 Intersect Healthcare, Inc. 3 3
    • MS‐DRG 573,574,575 Formerly DRG 263,264 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS‐DRG 574 (At this time Medical  Issue Name:  Necessity excluded from review) Description:  D i i DRG Validation requires that diagnostic and procedural information and the discharge status of the  DRG V lid i i h di i d d li f i d h di h f h beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician  description and the information contained in the beneficiary's medical record. Reviewers will validate for  MS‐DRG 574, previously DRG 263 and 264, principal diagnosis, secondary diagnosis, and procedures  affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service:  10/01/2007 ‐ Open States Affected:  Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina,  Oklahoma, South Carolina, Tennessee, Texas, Virginia (WPS only), West Virginia (WPS only) Additional Information:  Additional information can be found in the following manuals/publications: 1) ICD‐9‐CM Addendums and Coding Clinics ICD 9 CM Addendums and Coding Clinics  2) ICD‐9‐CM Vol. 1, 2 & 3, coding manuals  3) PIM Ch 6.5.3, Section A‐C DRG Validation Review Connolly Healthcare © 2010 2010 Intersect Healthcare, Inc. 4 4
    • MS-DRG 465 Formerly DRG 217 Wound Debridement and Skin Graft Except Hand, for Musculo‐Connective Tissue Disorders without CC/MCC:  Issue Name:  MS DRG 465 (At this time Medical Necessity excluded from review) MS‐DRG 465 (At this time Medical Necessity excluded from review) Description:  DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary,  as coded and reported by the hospital on its claim, matches both the attending physician description and the  information contained in the beneficiary's medical record. Reviewers will validate for MS‐DRG 465, previously  DRG 217, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service:  10/01/2007 ‐ Open States Affected:  Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma,  South Carolina, Tennessee, Texas, Virginia (WPS only), West Virginia (WPS only) Additional Information:  Additional information can be found in the following manuals/publications: 1) ICD‐9‐CM Addendums and Coding Clinics  2) ICD‐9‐CM Vol. 1, 2 & 3, coding manuals  3) PIM Ch 6.5.3, Section A‐C DRG Validation Review Connolly Healthcare © 2010 2010 Intersect Healthcare, Inc. 5 5
    • 86.22 Target of Other RAC MS-DRG’s 264 622 356 624 357 358 623 673 424 576 957 674 423 425 901 577 958 675 2010 Intersect Healthcare, Inc. 6 6
    • Excisional vs. Nonexcisional Debridement • Surgical Removal or cutting away of devitalized  86.22 Excisional tissue, necrosis , slough • Performed at pt bedside, the operating, or  Debridement emergency room • Only applies to skin and subcutaneous tissue,  can be performed on any part of the body • Nonoperative brushing, scrubbing, or washing  86.28  away of devitalized tissue, necrosis, or slough • Can include Maggot and Water jet therapy,  Nonexcisional lavage, whirlpools, scrapings, irrigation g , p , p g, g • Applies to only skin Debridement 2010 Intersect Healthcare, Inc. 7 7
    • What s What’s All the Fuss About with Excisional Debridement 8
    • Documentation Documentation must support the translation pp Terms “ Excisional debridement”, “Debridement of wound”, “Sharp debridement”, and etc. Are not enough to assign 86.22 Should note if the excision is beyond the wound margin, the type of area that was debrided, the type of instruments utilized in procedure, the number of areas debrided, specify location, and depth of the procedure If debridement is part of another procedure- check to see if include or excluded from separate coding 9
    • Documentation If documentation supports an extension beyond the skin or subcutaneous layer- 86.22 is the inappropriate code Use of scissors is not enough – can be used just to loosen fragments, look for scalpel, blade, lasers- “R f l kf l l bl d l “Removal of l f tissue” Measurements and appearance before and after Note any documentation that states debrided down to vitalized or healthy tissue 2010 Intersect Healthcare, Inc. 10 10
    • Auditing Cases for Excisional Debridement 2010 Intersect Healthcare, Inc. 11 11
    • Retrospective or Concurrent Case Mix  Index Diagnosis Excisional Debridement Documentation 2010 Intersect Healthcare, Inc. 12 12
    • Worksheet 1. Diagnoses of the patient: ( All current diagnoses and treatments) 2. Initial Size, Depth, and Location of Wound: 3. Debridement Type: Wound, Infection, Burn 4. Date of Order: ( Make note of exact order) 5. Is there any documentation that states the area is infected? Yes/No 6. Location of Procedure: Operating room Patient bedside Emergency room 7. 7 Clinical Title of professional performing the procedure Nurse Nurse Practioner Therapist Physician Assistant Physician 2010 Intersect Healthcare, Inc. 13 13
    • Worksheet Continued 7. Number of locations debrided: __________________________ 8. Post size and depth of areas:____________________________ 9. Type of tissue to that was debrided: Cutaneous a. necrotic Subcutaneous b. slough c. c devitalized 10. Was the area debrided beyond the dead or damaged tissue down to healthy, viable tissue? Yes/ No 11. Instruments utilized during procedure scalpel scissors laser blade 14
    • Worksheet Continued 12.Is there evidence of other procedures that include procedure code 86.22: Yes No 13. What type of dressings were applied to the debrided area? 14. Were any specimens sent to pathology? Yes/No 15. Discharge status: Home or Self Care -01 Discharged/ Transferred to a Short Term General Hospital for Inpatient Care -02 Discharged/ Transferred to a SNF with Medicare Certification in Anticipation of killed Care - 03 Discharged/Transferred to an Intermediate Care Facility - 04 Discharged/Transferred to Another Type of Health Care Facility Not elsewhere in the Code List- 05 Di h d/T f d t A th T f H lth C F ilit N t l h i th C d Li t Discharged/ Transferred to Home Care- 06 AMA -07 Expired-20 15
    • Highlights If it doesn’t meet the criteria- look for another more appropriate code Remember “ Cutting away of tissue” Translate within the guidelines Use the AHA Coding Clinics for guidance 2010 Intersect Healthcare, Inc. 16 16
    • AHA Coding Clinics on 86.22 DEBRIDEMENT THROUGH MULTIPLE LAYERS DEBRIDEMENT OF MULTIPLE LAYERS (SKIN, MUSCLE, BONE) OF THE SAME SITE IS CODED ONLY TO THE DEEPEST LAYER DEBRIDED. DO NOT ASSIGN TWO OR MORE CODES WHEN THE DEBRIDEMENT EXTENDS PAST THE SKIN AND SUBCUTANEOUS TISSUE INTO THE MUSCLE OR BONE (AHA CODING CLINIC FOR ICD-9-CM, 1999, FIRST QUARTER, PAGES 8-9). DEBRIDEMENT INTEGRAL TO PROCEDURE DEBRIDEMENT OF THE SKIN THAT IS PREPARATORY TO FURTHER SURGERY SHOULD NOT BE CODED AS A SEPARATE PROCEDURE (AHA CODING CLINIC FOR ICD-9-CM, 1991, THIRD QUARTER, PAGES 18-19). IN ADDITION, DO NOT ASSIGN CODE 86.22 WHEN DEBRIDEMENT OF AN OPEN FRACTURE SITE IS PERFORMED. DEBRIDEMENT OF THE SKIN IS CONSIDERED INHERENT FOR THIS PROCEDURE (AHA CODING CLINIC FOR ICD-9-CM, 1995, THIRD QUARTER, PAGE 12). WHO CAN PERFORM AN EXCISIONAL DEBRIDEMENT CAN BE CODED WHEN PERFORMED BY A NURSE NURSE, THERAPIST, PHYSICIAN ASSISTANT OR PHYSICIAN. (SEE CODING CLINIC, SECOND QUARTER 2004, PAGE 5, CODING CLINIC, SECOND QUARTER 2000, PAGE 9, AND CODING CLINIC, FOURTH QUARTER 1988, PAGE 5.) 2010 Intersect Healthcare, Inc. 17 17
    • AHA Coding Clinics Cont’d Laser debridement of wound  Laser debridement of wound down to bone is coded 86.22, excisional debridement of wound,  infection or burn, if this is not an open bone fracture or fracture/dislocation. Excisional debridement  of an open fracture site is coded to 79.60‐79.69. When there is no specific “destruction” code for  laser, laser technique is coded to the excisional codes (excluding those assignments under  photocoagulation of eye.) (See Coding Clinic, second quarter 1992, page 17, and Coding Clinic, third  q quarter 1989, page 1  ,p g Laser debridement of ulcer/repair/closure  Laser debridement of ischial decubitus ulcer down to bone with subsequent repair with skin flap  creation and closure is coded 86.22, excisional debridement of wound, infection or burn, and 86.89,  other repair and reconstruction of skin and subcutaneous tissue. The closure is included in the repair  and not coded separately. The repair procedure code needs to be based on the documentation in the  patient’s record. Code 86.89 indicates a nonspecific repair of the ulcer. (See Coding Clinic, second  quarter 1993, page 11, and Coding Clinic, second quarter 1992, page 17.)  quarter 1993 page 11 and Coding Clinic second quarter 1992 page 17 ) 18
    • References http://racmonitor.com/news/43-special-bulletin/174-racs-how-excisional-debridements-may- cut-deep.html t d ht l http://www.fortherecordmag.com/archives/091409p30.shtml http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_036237.hcsp?dDocNam e=bok1_036237 http://med.stanford.edu/shs/update/archives/DEC2006/coding_corner.htm 2010 Intersect Healthcare, Inc. 19 19
    • Appealing an Excisional Debridement Inpatient Denial Denise Wilson, MS RN RRT Director, Client Education and Performance Improvement Intersect Healthcare, Inc. 1
    • Learning Objectives Understand how to create a successful coding or medical necessity appeal for Excisional Debridement or Wound Care denials by: Understanding the Issue at Hand Providing a Road Map for the Reviewer Presenting a Preponderance of Best Evidence Understand how to tailor appeals to the Administrative Law Judge 2010 Intersect Healthcare, Inc. 2 2
    • Understanding the Issue at Hand From the RAC demonstration project: Top Services With RAC-Initiated Overpayment Collections (Net of Appeals):Cumulative Through 3/27/08 #2 on the list: Incorrect Coding of Excisional Debridement Resulted in $66.8 million in collected overpayments (less cases overturned on appeal) Top Services With Underpayments Refunded to Providers: Cumulative Through 3/27/08 #2 on the list: Incorrect Coding of Wound Debridement Resulted in $3 million in amount refunded THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM: An Evaluation of the 3-Year Demonstration, June 2008 https://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdf 2010 Intersect Healthcare, Inc. 3 3
    • Understanding the Issue at Hand Claim Facts The hospital coder assigned a procedure code of 86.22. In the medical record, the physician writes “debridement was performed.” Coding Clinic 1991Q3 states “Unless the attending physician documents in the medical record that an excisional debridement was performed (definite cutting away of tissue, not the minor scissors removal of loose fragments), debridement of the skin should be coded to 86.26, non excisional debridement of skin… Any debridement of the skin that does not meet the criteria noted above or is described in the medical record as debridement and no other information is available should be coded as 82.26.” 82 26 The RAC determined that the claim was INCORRECTLY CODED and issued a repayment request letter for the difference between the payment amount for the incorrectly correctly coded procedure and the payment amount for the correctly coded procedure. Corrective Actions Hospitals can be more careful when submitting claims for excisional debridement. Medicare claims processing contractors can remind hospitals about the importance of following the coding clinic guidelines when submitting claims for excisional debridement. THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM: An Evaluation of the 3-Year Demonstration, June 2008 https://www.cms.gov/RAC/Downloads/RACEvaluationReport 2010 Intersect Healthcare, Inc. 4 4
    • Understanding the Issue at Hand Definition of Excisional Debridement 86.22: Excisional debridement of wound, infection, or burn Removal by excision of: devitalized tissue necrosis slough 86.22 excludes: debridement of: abdominal wall (wound) (54.3) bone (77.60-77.69) muscle (83.45) of hand (82.36) nail (bed) (fold) (86.27) nonexcisional debridement of wound, infection, or burn (86.28) open fracture site (79.60-79.69) pedicle or flap graft (86.75) ICD 9 CM Procedure Codes 2010 Intersect Healthcare, Inc. 5 5
    • Understanding the Issue at Hand Coding of debridement of wound, infection, wound infection or burn Excisional debridement involves surgical removal or cutting away, as opposed to a mechanical (brushing, scrubbing, washing) debridement. For coding purposes, excisional debridement is purposes assigned to code 86.22. Nonexcisional debridement is assigned to code 86.28. Official ICD-9-CM Guidelines for Coding and Reporting ICD 9 CM Effective October 1, 2009 http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm 2010 Intersect Healthcare, Inc. 6 6
    • Understanding the Issue at Hand Documentation of Excisional Debridement What: Excisional debridement is the definite cutting away of devitalized tissue, necrosis, or slough that includes cutting outside or beyond the wound margin. Where: Excisional debridement can be performed in the operating room, p p g , emergency room or at patient’s bedside depending on circumstances such as patient’s condition or location availability. Who: An excisional debridement can be coded when performed by a nurse, therapist, physician assistant or physician. How: Documentation should note if the excision is beyond the wound margin, the type of area that was debrided, the type of instruments utilized in procedure, the number of areas debrided, the specific location, and depth of the procedure. 2010 Intersect Healthcare, Inc. 7 7
    • Providing a Road Map 2010 Intersect Healthcare, Inc. 8 8
    • Providing a Road Map 2010 Intersect Healthcare, Inc. 9 9
    • Providing a Road Map 2010 Intersect Healthcare, Inc. 10 10
    • Preponderance of Evidence SURGICAL TREATMENT OF BURNS Escharotomy Definition, Purpose, Technique Debridement of Burn Wounds Definition, Purpose, Definition Purpose Technique Excision of Burn Wounds Definition, Purpose, Technique American Burn Association. (2009) White Paper. Surgical M S i l Management of th B t f the Burn WWound and Use of d dU f Skin Substitutes. http://www.ameriburn.org/WhitePaperFinal.pdf?PHPSESS ID=fa7087753db2caaa8c5b21f53869457d 2010 Intersect Healthcare, Inc. 11 11
    • Preponderance of Evidence Wound Care Associations: The American College of Certified Wound Specialists — http://www.theccws.org/index.html American Professional Wound Care Association (APWCA) — www.apwca.org Association for the Advancement of Wound Care (AAWC) — www.aawconline.org www aawconline org National Alliance of Wound Care® (NAWC®) — www.nawccb.org Wound Ostomy Continence Nurses (WOCN) — www.wocn.org Dermatology Nurses’ Association (DNA) — www.dnanurse.org The Wound Healing Society — http://www.woundheal.org Free Access To The Chronic Wound Care Guidelines Free Access to the Acute Wound Care Guidelines 2010 Intersect Healthcare, Inc. 12 12
    • Parting Thoughts Use the guidelines that were available and in effect at the  Use the guidelines that were available and in effect at the time the services were provided, coded, and billed! Provide clear and accurate reference information,  including URLs. Include all supporting guidelines in full text documents  pp gg (the pertinent pages) as attachments to your appeal. 2010 Intersect Healthcare, Inc. 13 13
    • Summary Best Practice for Appeal Determine if documentation in the chart supports an appeal Support the coding decision with: ICD‐9‐CM Coding Guidelines IC 9 CM Official Guidelines for Coding and Reporting ICD‐9‐CM Official Guidelines for Coding and Reporting  American Hospital Association's (AHA) Coding Clinic for ICD‐9‐CM Support the physician’s decision making process with evidence based guidelines Use CMS’s coverage policies and guidelines 2010 Intersect Healthcare, Inc. 14 14
    • Resources THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM: An Evaluation of the 3-Year Demonstration, June 2008 https://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdf Official ICD-9-CM Guidelines for Coding and Reporting Effective October 1, 2009 http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm American Burn Association. (2009) White Paper. Surgical Management of the Burn Wound and Use of Skin Substitutes. http://www.ameriburn.org/WhitePaperFinal.pdf?PHPSESSID=fa7087753db2 caaa8c5b21f53869457d Guidelines to decrease the impediment to acute wound healing caused by nonviable tissue Wound Rep Reg (2008) 16 723–748 _c 2008 by the Wound Healing Society http://www.woundheal.org 2010 Intersect Healthcare, Inc. 15 15