The documentation standard for coding excisional debridement did not change with the use of ICD-10-PCS reporting. The provider must document “excisional debridement” or clearly document/describe the procedure as being an “excision” of the tissue being debrided.
Excisional debridement is surgical removal (cutting away) of tissue, necrosis, or slough. This is classified to the root operation of “Excision” in PCS. Excisional debridement involves the use of a sharp instrument, like a scalpel, to cut away/remove devitalized tissue.
A code for excisional debridement is assigned when the physician documents “excisional debridement” or if the physician has clearly documented removal of tissue by excision (cutting out or off, without replacement, a portion of a body part).
The use of a sharp instrument alone is not sufficient for reporting excisional debridement. Documentation of knife dissection is not sufficient for reporting to the root operation of “excision”.
Non-excisional debridement is the nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis, slough, or foreign material. Most non-excisional debridement procedures will be classified to the root operation of “Extraction” (pulling or stripping out or off all of a portion of a body part by the use of force). Debridement using a Versajet Debrider is reported as a non-excisional debridement.
When both excisional and non-excisional debridement is performed at the same site, only the excisional debridement code would be coded. The excision is the definitive treatment at the site.
It is the coder’s responsibility to read the documentation provided and determine what root operation the documentation equates to in the PCS definitions. Physicians are not expected to use terms associated with the PCS code descriptions.
Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P
AHA Coding Clinic, Third Quarter 2015; Pages 3-8
AHA Coding Clinic, First Quarter 2013 Pages: 15-17
ICD-10-PCS Official Guidelines for Coding and Reporting 2016
AHA Coding Clinic, Third Quarter 2016 Pages: 20-22
AHA Coding Clinic, First Quarter 2018 Pages: 14-15
AHA Coding Clinic, Third Quarter 2018 Pages: 17-18
Health Information Associates offers medical coding services, medical auditing services, and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities in the United States.
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
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