Wound Care Presentation

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Wound CareWound CareDocumentation Documentation Documentation Documentation

IssuesIssues

Tracey Goessel, M.D.CEO

FairCode AssociatesFairCode Associates

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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!)

22010 Intersect Healthcare, Inc. FairCode

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What is associated with the wound?

Open Wounds -- Lacerations

What is associated with the wound?Be certain to capture associated injuries

Does the wound meet the definition of complicated?

Delayed healingDelayed treatmentForeign body orMajor Infection

How was the wound treated?Dermabond coded as application of tissue Dermabond coded as application of tissue adhesivesCapture length of wound and layers closed


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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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Decubitus Ulcers: Describe Location and Stage!Stage I

Persistent, focal erythema

Stage IIPressure ulcer with abrasion, blister, partial thickness skin loss involving epidermis and/or dermis

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Decubitus Ulcers, Continued

Stage IIIFull thickness skin loss involving damage or necrosis of subcutaneous tissue

Stage IVNecrosis of soft tissues through to underlying muscle, tendon or bone

tissue


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Are they diabetic in origin or decubitus?

Skin Ulcers: Describe Source

Are they diabetic in origin, or decubitus?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 physician identifies it as a diabetic complication."

Query, query, query!


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Coding Clinic Second Quarter 1994

Skin Ulcers: Describe Source

Coding Clinic, Second Quarter 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 if one is not stated by the 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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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.”

Q ! Query, query, query!


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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 eco d that an e cisional deb idement as medical record that an excisional debridement was performed.”

Coding Clinic, Fourth Quarter 1988 Page: 5


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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 physician.”y , p , p y

“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 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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Wound Treatment

h lOasis matrix burn dressing

Code as application of wound dressing

Escharotomy no longer excisional debridement of skin

is now re-indexed to code 86.09, Other incision of skin and subcutaneous ti etissue.


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Maggots!

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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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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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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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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Excisional DebridementExcisional DebridementExcisional DebridementExcisional Debridement

Charmira Orr BS,LPN,CCS,CPC,CCDS, Director of Coding and Auditing

Intersect Healthcare

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Participants will understand how to utilize

Learning Objectives

Participants will understand how to utilize the RAC demonstration area target on Excisional Debridement to perform internal auditsParticipants will review and understand highlights to include in audits when focusing on excisional debridementParticipants will review and understand the ICD-9 CM guidelines for assigning 86 22 Excisional Debridement86.22 Excisional Debridement

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86 22 Excisional Debridement #1

The RAC Demonstration

86.22 Excisional Debridement #1 procedure code that was coded incorrectly

Coding errors directly contributed to understanding guidelines, documentationg g ,

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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MS‐DRG 573,574,575 Formerly DRG 263,264Issue Name:

Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS‐DRG 574 (At this time Medical Necessity excluded from review)

D i i DRG V lid i i h di i d d l i f i d h di h f hDescription: 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 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

2010 Intersect Healthcare, Inc. 4

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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MS-DRG 465 Formerly DRG 217

Issue Name: Wound Debridement and Skin Graft Except Hand, for Musculo‐Connective Tissue Disorders without CC/MCC: 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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86.22 Target of Other RAC MS-DRG’s

264 622

357

356

358

424 576

623

624

673

957 674

423

424

425

576

577


901

957

958

674

675

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Excisional vs. Nonexcisional Debridement

• Surgical Removal or cutting away of devitalized tissue, necrosis , slough

• Performed at pt bedside, the operating, or emergency room

• Only applies to skin and subcutaneous tissue, can be performed on any part of the body

86.22 Excisional

Debridement

• Nonoperative brushing, scrubbing, or washing away of devitalized tissue, necrosis, or slough

• Can include Maggot and Water jet therapy, lavage, whirlpools, scrapings, irrigation

86.28 Nonexcisional g , p , p g , g

• Applies to only skinDebridement


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What’s All the Fuss About What s All the Fuss About with Excisional Debridement

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DocumentationDocumentation must support the translationpp

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 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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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 f l k f l l bl d l “R l f fragments, look for scalpel, blade, lasers- “Removal of tissue”

Measurements and appearance before and after

Note any documentation that states debrided down to vitalized or healthy tissue


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Auditing Cases for Excisional Debridement


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Retrospective or Concurrent

ExcisionalDebridement

Diagnosis

Case Mix Index

Documentation

Debridement


Documentation

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Worksheet1. 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 roomPatient bedsideEmergency room

7 Clinical Title of professional performing the procedure7. Clinical Title of professional performing the procedureNurseNurse PractionerTherapistPhysician AssistantPhysician


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Worksheet Continued7. Number of locations debrided: __________________________

8. Post size and depth of areas:____________________________

9. Type of tissue to that was debrided: Cutaneous a. necroticSubcutaneous b. slough

c devitalizedc. devitalized10. Was the area debrided beyond the dead or damaged tissue down to healthy, viable tissue?Yes/ No

11. Instruments utilized during procedurescalpelscissorsscissorslaserblade

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Worksheet Continued12.Is there evidence of other procedures that include procedure code 86.22: YesNo

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 -01Discharged/ Transferred to a Short Term General Hospital for Inpatient Care -02Discharged/ Transferred to a SNF with Medicare Certification in Anticipation of killed Care - 03Discharged/Transferred to an Intermediate Care Facility - 04Di 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 05Discharged/Transferred to Another Type of Health Care Facility Not elsewhere in the Code List- 05Discharged/ Transferred to Home Care- 06AMA -07Expired-20

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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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DEBRIDEMENT THROUGH MULTIPLE LAYERS

AHA Coding Clinics on 86.22

DEBRIDEMENT THROUGH MULTIPLE LAYERSDEBRIDEMENT 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 PROCEDUREDEBRIDEMENT OF THE SKIN THAT IS PREPARATORY TO FURTHER SURGERY 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 PERFORMAN EXCISIONAL DEBRIDEMENT CAN BE CODED WHEN PERFORMED BY A NURSE AN EXCISIONAL DEBRIDEMENT CAN BE CODED WHEN PERFORMED BY A 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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AHA Coding Clinics Cont’dLaser 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 quarter 1989, page 1 q , 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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http://racmonitor.com/news/43-special-bulletin/174-racs-how-excisional-debridements-may-t d ht l

References

cut-deep.html

http://www.fortherecordmag.com/archives/091409p30.shtml

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_036237.hcsp?dDocName=bok1_036237

http://med.stanford.edu/shs/update/archives/DEC2006/coding_corner.htm


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Appealing an Appealing an Excisional Excisional

Debridement Debridement Inpatient DenialInpatient Denial

Denise Wilson, MS RN RRTDirector, Client Education and Performance

ImprovementIntersect Healthcare, Inc.

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Understand how to create a successful

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 HandProviding a Road Map for the ReviewerPresenting a Preponderance of Best Evidence

Understand how to tailor appeals to the Administrative Law Judge


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From the RAC demonstration project:

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 DebridementResulted in $66.8 million in collected overpayments (less cases overturned on appeal)cases overturned on appeal)

Top Services With Underpayments Refunded to Providers: Cumulative Through 3/27/08

#2 on the list: Incorrect Coding of Wound DebridementResulted 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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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 ”available should be coded as 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 ActionsHospitals 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 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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Definition of Excisional Debridement


Definition of Excisional Debridement86.22: Excisional debridement of wound, infection, or burnRemoval by excision of:

devitalized tissuenecrosis slough

86.22 excludes:debridement of: 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 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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Coding of debridement of wound infection


Coding of debridement of 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 For coding purposes, excisional debridement is assigned to code 86.22.Nonexcisional debridement is assigned to code 86.28.

Official ICD-9-CM Guidelines for Coding and ReportingOfficial ICD 9 CM Guidelines for Coding and ReportingEffective October 1, 2009

http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm


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Documentation of Excisional Debridement


Documentation of Excisional DebridementWhat:

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 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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Providing a Road Map


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SURGICAL TREATMENT OF BURNS

Preponderance of Evidence

SURGICAL TREATMENT OF BURNS Escharotomy

Definition, Purpose, Technique

Debridement of Burn WoundsDefinition Purpose TechniqueDefinition, Purpose, Technique

Excision of Burn WoundsDefinition, Purpose, Technique

American Burn Association. (2009) White Paper.S i l M t f th B W d d U f Surgical Management of the Burn Wound and Use of

Skin Substitutes. http://www.ameriburn.org/WhitePaperFinal.pdf?PHPSESS

ID=fa7087753db2caaa8c5b21f53869457d


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Wound Care Associations:

Preponderance of Evidence

Wound Care Associations:The American College of Certified Wound Specialists —http://www.theccws.org/index.htmlAmerican Professional Wound Care Association (APWCA) —www.apwca.orgAssociation for the Advancement of Wound Care (AAWC) —www aawconline orgwww.aawconline.orgNational Alliance of Wound Care® (NAWC®) —www.nawccb.orgWound Ostomy Continence Nurses (WOCN) — www.wocn.orgDermatology Nurses’ Association (DNA) —www.dnanurse.orgThe Wound Healing Society — http://www.woundheal.orgThe 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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Use the guidelines that were available and in effect at the

Parting Thoughts

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 g g(the pertinent pages) as attachments to your appeal.


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Best Practice for Appeal

Summary

Best Practice for AppealDetermine if documentation in the chart supports an appealSupport the coding decision with:

ICD‐9‐CM Coding Guidelines

ICD‐9‐CM Official Guidelines for Coding and Reporting IC 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 guidelinesUse CMS’s coverage policies and guidelines


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THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM:

Resources

An Evaluation of the 3-Year Demonstration, June 2008https://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdf

Official ICD-9-CM Guidelines for Coding and ReportingEffective October 1, 2009http://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 tissuenonviable tissue

Wound Rep Reg (2008) 16 723–748 _c 2008 by the Wound Healing Societyhttp://www.woundheal.org


Health & Medicine

Wound Care Presentation