In: Nursing
Assign ICD -10 PCS codes to the following procedure statement. List the root operation selected and the code assigned?
Q. Non-excisional debridement of stage 3 pressure ulcer of subcutaneous tissue of buttock?
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 by the use of a Versajet Debrider is reported as a non-excisional debridement.
Debridement:
• Excisional see Excision.
• Non-excisional see Extraction.
The definitions from CMS are as follows: Volume No. 2 • Excision: Cutting out or off, without replacement, a portion of a body part. •
Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force. As you can see, not only the debridement issue not go away with PCS, it can get worse as coders can code excision or extraction on almost any body part. The following important elements need to be found in the medical record to support assignment of the correct code: • Condition requiring debridement (e.g., ulcer, fracture); • Site of the debridement (e.g., foot, sacrum); • Extent and depth of debridement (e.g., code to the deepest level [layer] of tissue); • Method(s) used to remove tissue (e.g., a definite cutting away of tissue); • Specific type of tissue being removed (e.g., skin, subcutaneous, muscle, bone or tendon) ; • A cutting of tissue outside or beyond the wound margin; and • Lateriality.