Document what you do – or else it didn’t happen

By Raymond Janevicius, MD
04/23/2012 at 2:00PM
If it's not documented, it didn't happen. This is the mantra for medico-legal records, and it holds true in the insurance and reimbursement milieus when justifying CPT coding of a surgical procedure. If the medical record does not accurately document what is done, the services cannot be reported for reimbursement purposes.

‘Insurance denied my procedure!'

Consider this scenario: A plastic surgeon performs a tangential excision of a 50 sq cm burn of the thigh with a split thickness skin graft (STSG). The procedure is reported with codes 15100 and 15002-51, the correct coding of the procedures performed. The insurance company denies code 15002.

At first glance, this seems unfair. A tangential excision is an extensive procedure and appropriately reported with code 15002. Why did the payer deny reimbursement for this procedure? Examination of the operative report reveals that the only description of the tangential excision reads: "The burn was debrided." Yes, this may be the clinical terminology we use, but in the language of coding (and hence, reimbursement), this should read "wound excision," "wound preparation" or "tangential excision."

A tangential excision is a "wound preparation," or in CPT terminology, a "surgical preparation." The operative report should have a description such as: "The burn eschar was tangentially excised, sequentially excising tissue to brisk bleeding in preparation for skin grafting." Accurately describe and document what's actually done in the O.R., so that it's clear in the medical record and will hold up to reviewer scrutiny.

Other scenarios

What was actually done: Granulation tissue is scraped off a wound of the foot, and a 50 sq cm STSG is placed.

What was reported: 15120; 15004-51

What was dictated: "The wound is debrided."

What insurance approved: 15120

Here, scraping of granulation tissue has been reported separately. This minimal maneuver is considered part of straightforward preparation of a recipient bed for grafting, and is included in the global grafting code, 15120.

What was actually done: A 15 sq cm venous stasis ulcer of the leg is sharply debrided, including subcutaneous tissue, to brisk bleeding, and a skin substitute placed.

What was reported: 15271; 11042-5

What was dictated: "The wound is debrided."

What insurance approved: 15271

Although the surgeon debrides the wound, including subcutaneous tissues, to healthy tissue, this is not described in the operative report, so code 11042 is denied. No size or depth is indicated, so it is not reportable.

What was actually done: A 5 X 3 cm full thickness burn of the dorsum of the hand is tangentially excised, and a full thickness graft placed.

What was reported: 15240; 15004-51

What was dictated: "The wound is debrided."

What insurance approved: 15240

The meticulous tangential excision required on the dorsum of the hand, to excise burned tissue, but preserve the underlying tendons, is not described in the operative report. Merely indicating that "the wound is debrided" belies the extent of the wound preparation that is performed prior to skin grafting.

What was actually done: A crush avulsion wound with devitalized tissue of the thigh measuring 20 X 10 cm is excised to healthy tissue and a STSG is applied.

What was reported: 15100; 15101; 15002-51; 15003

What was dictated: "The wound is debrided."

What insurance approved: 15100

This is an extensive procedure. There's no description of the size of the wound, the extent of the debridement nor the size of the skin graft. Simple debridement is included in the global grafting code. Since no description of the size appears in the operative report, only the first 100 sq cm are allowed: 15100.

What was actually done: An open comminuted fracture of the thumb metacarpal is debrided, including skin, subcutaneous tissue, and bone, with extensive cleansing and removal of all devitalized tissue. An open reduction of the fracture is performed.

What was reported: 26615 11012-51

What was dictated: "The wound is debrided."

What insurance approved: 26615

The excision of devitalized tissue in a fracture site is an involved procedure in preparation for open reduction of the fracture. The description of this preparation must be clear and accurate. Again, "The wound is debrided" belies the extent of what is actually done. The fracture wound excision codes use the confusing terminology "excisional debridement" to describe wound preparation for fracture reduction. With appropriate documentation this is separately reportable with code 11012.

What was actually done: A necrotizing fasciitis of the abdominal wall requires emergent excision of half the abdominal wall prior to placing a negative pressure wound device (VAC dressing).

What was reported: 11005; 97606-51

What was dictated: "The wound is debrided."

What insurance approved: 97605

Here the surgeon is only reimbursed for the VAC dressing after this three-hour emergent procedure! The insurer has taken advantage of the poor documentation and pays only on the lesser value code. The operative report should have a clear, detailed description of the extent of the wound (including dimensions) and of the wound excision procedure. The size of the wound is not documented, so the insurer again takes advantage of the poor documentation and pays on the lesser value code, 97605.

Note the significant differences

Although all these wounds are "debrided," the lack of description and the lack of use of appropriate terminology result in denial of these claims. If the operative report only indicates "The wound is debrided," then no amount of appeal or explanation to the payer will result in payment. The operative report must clearly indicate exactly what is done with the wound prior to grafting.

These are not errors on the part of insurance companies processing claims. They are inadequate descriptions of the procedures in the operative reports. Realize that there's more and more scrutiny of medical records by payers - so clear, complete, accurate documentation of what you do is extremely important. We plastic surgeons perform extensive procedures. Our operative reports must document exactly what we do, to justify the codes we submit and reimbursement we receive.

Remember, from an insurance/reimbursement standpoint, as well as medico-legally, if it's not documented in the operative report, it didn't happen

Code of the Month

The following Code of the Month illustration has been recounted from the dictation of an actual operative report.

History: An 80-year-old female - on prednisone and warfarin - fell, striking her pretibial area and suffering an crush-avulsion injury to the soft tissues.

Exam: A 15 X 10 cm distally based flap over the mid-tibia is present. The flap is crushed, hemorrhagic and retracted, with underlying hematoma. Most of the flap is not viable.

Surgery: The patient was placed under general anesthesia and the area prepped and draped. Most of the avulsion flap was necrotic, requiring debridement. The underlying hematoma was drained. Devitalized tissue was excised full thickness including skin and subcutaneous tissue to the underlying fascia, which was intact and viable. Total excision measured 13 X 10 cm. The area was covered with a 130 sq cm STSG from the thigh...


15100 STSG, leg, first 100 sq cm

15101 STSG, leg, each additional 100 sq cm

15002-51 Surgical preparation by wound excision, leg, first 100 sq cm

15003 Surgical preparation by wound excision, leg, each additional 100 sq cm

  • This is a formal wound excision ("surgical preparation") to prepare the wound for skin grafting, so the 15002-15003 series is appropriate. Although the surgeon uses the term "debridement," further description indicates a full thickness excision of tissues in preparation for skin grafting, a "surgical preparation."
  • The extent of the wound and its dimensions are clearly indicated, as is the size of the excision. There's no question as to the size of the excision or the size of the graft.
  • Total excision measures 130 sq cm, reported with codes 15002 and 15003.
  • Total grafting measures 130 sq cm. This is reported with codes 15100 and 15101.
  • Codes 15101 and 15003 are add-on codes and do not take the multiple procedure modifier, 51.
  • Evacuation of hematoma is included in wound preparation and is not separately reportable.