Is it or is it not excisional debridement?

Purpose:

Recovery Audit Contractors (RAC’s) are utilized by the Department of Health and Human Services to identify Medicare overpayments and underpayments. Millions of dollars in overpayments have been recouped after determining coding of excisional debridement procedures were inappropriate.  Amounts recovered have ranged from $305.00 to $211,816.83.  These cases are often reviewed by non-nursing and non-physician personnel.  

Excisional debridement is often performed in the operating room, emergency room, or at the patient’s bedside and can be performed by specialty nurses, physical therapists, and physicians.  Documentation of “excisional debridement” is not enough to substantiate the diagnosis.  This project describes best practices for medical record documentation to support the procedure of excisional debridement and outlines the appeals process currently utilized.

Method:

Data was collected from 2009 to 2013 and included 374 overpayment determinations related to assignment of code 86.22 (excisional debridement).  

Results and Discussion:

The cases that were successfully appealed contained details of the procedure and instruments that were used, described the extent and depth of the procedure, and documented a definite cutting away of tissue outside or beyond the wound margin.  There were issues with misinterpretation by RAC, medical records with scattered documentation that needed to be compiled, and others completed after provider query.  

Inappropriate take-backs are being recognized on lower levels of appeal. However, many appeals still require a final decision from an Administrative Law Judge (sometimes non-clinical) and years after the appeals process has begun.

Conclusion:

Criteria for excisional debridement have become a target area for RAC.   There is a continuous need for provider and staff education in order to improve documentation and provide complete and accurate clinical data.  Recommendations are made for process improvement to prevent further documentation issues and denials of excisional debridement.