Updated on: June 22, 2012

RACs: How Excisional Debridements May Cut Deep

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Original story posted on: June 9, 2009

ernie

By Ernie de los Santos

 

During the RAC demonstration project, one of the most lucrative recoupment areas was excisional debridements.

 

In fact, if you look in tables 2-6 from the RAC status document published in November 2007, excisional debridement was easily the leading service in terms of identifying errors, raking in recoupment dollars and surviving appeals.


Based on that alone, we can surmise that the RACs will continue to focus on it in the permanent project.

 

Here is a simple yet common example of an excisional debridement claim that a RAC determined to be incorrectly coded:

 

  • A physician wrote in the medical record that "debridement was performed."

 

  • Procedure code 86.22 was assigned by a coder.

A complex review was conducted and the RAC determined that the procedure should have been coded 86.28, because there was no reference to "excisional" and no indication that it was in fact the physician who performed the procedure.

 

Today, however, a RAC might not make this same decision. According to the rules issued by Coding Clinic in the fourth quarter of 1998, the denial decision was correct, but those rules were superseded by a slightly different set of regulations issued in the second quarter of 2000. By then, CMS decided that excisional debridement could be performed by a nurse, therapist, physician assistant, or a physician.

 

Nevertheless, the physician still must document "excisional debridement" in the record, or it won't matter. Remember: not documented = not done.

 

Also, it is important for physicians to know that simply stating "excisional debridement was performed" is simply not enough detail. Why? Because the definition (in ICD-9-CM Volume 3) of procedure code 86.22 states that it must include "removal by excision of devitalized tissue, slough or necrosis." This can be done by a sharp instrument, or even a laser, however the service must be described further as a cutting away of tissue, not simply the removal or scraping away of loose skin. In addition, there are some things specifically excluded by the definition: it cannot include debridement of abdominal wall, bone, muscle or nails, nor non-excisional debridements, open fracture debridements, or pedicle or flap graft debridements.

 

Splitting Hairs; Huge Impact

 

It may seem like CMS is splitting hairs here: after all, the care is being given and we're not even talking about medical necessity, so what's the big deal? What difference does it make? To a patient, perhaps none. To a facility, however, it's HUGE.

 

Without going into details here, there is a course at RAC University that shows exactly how the difference could be as much as $6,600 for a single claim. The course is entitled Excisional Debridements.

 

Watch a short preview of the course HERE.

 

About the Author

Ernie de los Santos has more than 20 years of experience in research and development, mostly centered on the use of computers, the Internet and the use of digital applications for new business models. During the past 30 years, he has worked on projects as a consultant and as an employee for several Fortune 100 corporations including Coca-Cola, the National Football League, Adobe, Sony, Panasonic and the People's Republic of China Ministry of Education. He is the chief technical officer and vice president of business development for eduTrax®

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