Wound Care Documentation Issues

1. Wound Care
Documentation
Issues
Tracey Goessel, M.D.
CEO
FairCode Associates
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2. 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!)
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3. 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
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4. 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)
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5. 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
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6. 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
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7. 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!
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8. 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!
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9. 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 !
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10. 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
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11. 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
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12. 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
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13. Wound Treatment
Maggots!
“Assign code 86.28, Nonexcisional debridement
of wound, infection or burn, for maggot
therapy.”
Coding Clinic, Second Quarter 2001 Page: 18
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14. 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.
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15. 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?
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16. 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.
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17. Excisional Debridement
Charmira Orr BS,LPN,CCS,CPC,CCDS,
Director of Coding and Auditing
Intersect Healthcare
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18. 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
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19. 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
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20. 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
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21. 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
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22. 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
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23. 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
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24. What s
What’s All the Fuss About
with Excisional Debridement
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25. 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
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26. 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
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27. Auditing Cases for
Excisional Debridement
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28. Retrospective or Concurrent
Case Mix
Index
Diagnosis
Excisional
Debridement
Documentation
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29. 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
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30. 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
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31. 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
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32. 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
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33. 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.)
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34. 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 )
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35. 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
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36. Appealing an
Excisional
Debridement
Inpatient Denial
Denise Wilson, MS RN RRT
Director, Client Education and Performance
Improvement
Intersect Healthcare, Inc.
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37. 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
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38. 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
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39. 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.”
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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
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40. 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
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41. 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
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42. 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.
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43. Providing a Road Map
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44. Providing a Road Map
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45. Providing a Road Map
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46. 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
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47. 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
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48. 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.
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49. 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
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50. 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
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