4/8/2016. Wound Care Coding and Documentation Basics ICD-10. Topics. By: Dana Sorenson- CPC. ICD-10 as it pertains to Wound Care.

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1 Wound Care Coding and Documentation Basics By: Dana Sorenson- CPC Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. Topics ICD-10 as it pertains to Wound Care E&M Basics Documentation and Coding of Wound Debridement Coding of Skin Graft Substitutes Questions 2 ICD-10 Went from 13,000 ICD-9 codes to approximately 68,000 codes in ICD-10. This means codes are more specific and documentation is key! Each note should stand alone and should contain the specific information needed to code that visit and the wounds being treated. 3 1

2 Key Information to Document for ICD-10 Type of Wound- Venous, Diabetic, Ischemic, Pressure, Non-Pressure etc. Laterality of wound- Left/Right/bilateral Location of Wound Depth of Wound Stage of Pressure ulcer Depth of non-pressure ulcer Limited to Breakdown of Skin Fat Layer Exposed Necrosis of Muscle Necrosis of Bone 4 E&M Basics The initial evaluation of the patient and their wound(s) is billable separately from the treatment/debridement. Assign the appropriate new or established patient code in addition to the debridement code. After the initial assessment, no additional E&M code should be reported with the treatment/debridement unless a new/separate problem is being addressed. 5 E&M Basics Cont. Can choose E&M code based on components (i.e. history, exam and medical decision making) or bill based on time with the appropriate time statement. I spent X amount of time with the patient, over half of which was spent in counseling and coordination of care discussing X, Y and Z. Debridement and H&P can be dictated separately or combined into one note as long as the details of both services are documented. 6 2

3 Debridement Coding and Documentation Types of Debridement- Excisional- chart notes must clearly describe the tissue as being cut away with sharp tools such as scissors, scalpel, forceps, etc. ( and ) Non-excisional- removal of devitalized tissues without cutting such as irrigation, scrubbing, washing, etc. (97602) 7 Excisional Debridement Superficial Selective Debridement-down into and including the epidermis and dermis (97597 and 97598) Surgical Debridement- More extensive debridement of the underlying tissue Subcutaneous (11042 and 11045) Muscle/Fascia (11043 and 11046) Bone (11044 and 11047) 8 Key Tips for Debridement Documentation Location of the wound- Site and laterality The more specific, the better. Unspecified ICD-10 codes often not covered. Level of debridement- ALWAYS document the depth to which you debrided the wound(s) Dermis/epidermis SubQ Muscle/Fascia Bone Depth of wound important for both diagnosis and procedural coding! Both ICD-10 codes and CPT codes need depth documented in order to choose the most specific code. 9 3

4 Key Tips for Debridement Documentation cont. Size of Debridement- Size of wound and size of debridement aren t necessarily the same and cannot be assumed so. CPT codes are chosen based on increments of 20 square centimeters or part thereof. If there is more than one wound, the sum area of all wounds at the same depth are added together. Coding starts over (addition of surface area) for wounds of different depths. State the tool used to debride the wound such as scissors, scalpel, forceps, etc. 10 Key Tips for Debridement Documentation cont. For documentation purposes, the objective assessment of the wound should also be noted. General appearance Improving/worsening Continuing plan of care Each note should stand alone and include the information needed to document the ICD-10 and CPT code billed. Debridement codes do not include the treatment of burns ( ) Debridement codes do include treatment of injuries, wounds, chronic ulcers and infections. 11 Skin graft substitute codes are chosen based on increments of 25 square centimeters up to 100 square centimeters. There are additional codes for a graft greater than 100 square cm. 12 4

5 Codes are based on anatomical location and size of graft- Less than 100 square cm first 25 square cm- trunk, arms (wrist), legs (ankle) (each additional 25 square cm up to 100 square cm) first 25 square cm-face, scalp, eyelids, moth, neck, ears, genitalia, hands/feet, digits (each additional 25 square cm up to 100 square cm) Greater than 100 square cm greater than or equal to 100 square cm- trunk, arms, legs each additional 100 square cm greater than or equal to 100 square cm- face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, digits each additional 100 square cm 13 Per CPT Add together the surface area of multiple wounds in the same anatomical locations as indicated in the code descriptions. Do NOT add together multiple wounds at different anatomical site groups. Codes include simple debridement - Epidermis, Dermis and SubQ (97597/11042). Can bill debridement of muscle/fascia and/or bone separately (11043/11044). 14 If you place a skin graft substitute on one wound and debride another wound at a different site, report both codes with a modifier. (XS) 15 5

6 Conclusion Documentation is key! The more specific the better! Check LCDs and NCDs for guidelines. Questions?? 16 6

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