March 18, 2015 | | Comments 0
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Q&A: Coding an excisional debridement

Ask your question by responding in the comment section.

Ask your question by responding in the comment section.

Q: Where can I go to find out if the word “excisional” must be written by the doctor to code an excisional debridement?

A: Many professional coders will say that the physician must include the  word excisional in order to assign a code for excisional debridement.. I always taught students to use this word as well. So let’s start our investigation as to where this rule came from by taking a look at the Official Guidelines of Coding and Reporting. If there isn’t any direction here (and in this case, there isn’t) we’d turn to the instructions in the alphabetic and tabular index of the code set. Actually, we should really start with the index, as these guidelines need to be applied first when assigning a code..

At code 86.22, excisional debridement of a wound, infection or burn, states “for removal by excision of: devitalized tissue, necrosis, and slough.” No other terms or synonyms are used to describe how the tissue was removed, except for excision. So physicians need to use that word specifically.

Now if you are debating this with a surgeon, he or she will have little desire to understand the inner workings of the code book. However, a number of AHA Coding Clinics offer guidance.

Specifically, AHA Coding Clinic for ICD-9-CM, First Quarter, 2013, states that the requirements in the index were intended to “encourage improved documentation…as to the type of debridement performed.” It includes an example of a patient with a traumatic open wound, stating that clinically an excisional debridement may not be clinically performed and that in many cases a nonexcisional debridement may be needed to clear the problematic area.

“Clear and concise documentation is needed,” Coding Clinic states. “It is critical that hospitals work with their providers to ensure that the documentation used to support excisional debridement clearly describes the procedure.”

Editor’s Note: The ACDIS Forms & Tools Library also includes sample query forms. For more information regarding this topic see these additional articles:

© Copyright 1984-2014, American Hospital Association (“AHA”), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.

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Katherine Rushlau About the Author: Katherine "Katy" Rushlau is the CDI Editor for ACDIS at HCPro.

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