The Skinny on Improper Coding of Skin and Connective Tissue Procedures

on Tuesday, 30 July 2013. All News Items | Case Management | Coding

In the world of Recovery Auditors the denial spotlight currently seems to be on denials due to lack of medical necessity.  However, it is important to remember that they are continuing to perform DRG validation reviews too.  

The Medicare Administrative Contractor for Alabama, Georgia and Tennessee (Cahaba GBA) posted a notice on July 18, 2013 regarding Improper Coding and Medical Necessity Denials for Skin and Connective Tissue Procedures.  This issue was identified from the April 2013 CMS Corrective Action A/B Report.  The Recovery Auditors identified the following DRGs as having the potential for improper coding:

MS-DRGMS-DRG Description
463 Wound Debridement & Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC
464 Wound Debridement & Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC
465 Wound Debridement & Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without CC/MCC
477 Biopsies of Musculoskeletal System and Connective Tissue with MCC
478 Biopsies of Musculoskeletal System and Connective Tissue with CC
479 Biopsies of Musculoskeletal System and Connective Tissue without CC/MCC
500 Soft Tissue Procedures with MCC
501 Soft Tissue Procedures with CC
502 Soft Tissue Procedures without CC/MCC
515 Other Musculoskeletal System and Connective Tissue O.R. Procedures with MCC
516 Other Musculoskeletal System and Connective Tissue O.R. Procedures with CC
517 Other Musculoskeletal System and Connective Tissue O.R. Procedures without CC/MCC
573 Skin Graft &/or Debridement for Skin Ulcer or Cellulitis with MCC
574 Skin Graft &/or Debridement for Skin Ulcer or Cellulitis with CC
575 Skin Graft &/or Debridement for Skin Ulcer or Cellulitis without CC/MCC
576 Skin Graft &/or Debridement Except for Skin Ulcer or Cellulitis with MCC
577 Skin Graft &/or Debridement Except for Skin Ulcer or Cellulitis with CC
578 Skin Graft &/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC
579 Other Skin, Subcutaneous Tissue and Breast Procedures with MCC
580 Other Skin, Subcutaneous Tissue and Breast Procedures with CC
581 Other Skin, Subcutaneous Tissue and Breast Procedures without CC/MCC
622 Skin Grafts & Wound Debridement for Endocrine, Nutritional & Metabolic Disorders with MCC
623 Skin Grafts & Wound Debridement for Endocrine, Nutritional & Metabolic Disorders with CC
624 Skin Grafts & Wound Debridement for Endocrine, Nutritional & Metabolic Disorders without CC/MCC
901 Wound Debridements for Injuries with MCC
902 Wound Debridements for Injuries with CC
903 Wound Debridements for Injuries without CC/MCC
904 Skin Grafts for Injuries with CC/MCC
905 Skin Grafts for Injuries without CC/MCC

Coding Errors Examples provided in this post:

Example 1:

  • Patient presented with exposed hardware and soft tissue infection after a cervical fusion.
  • Per the operative note this patient underwent removal of instrumentation and segmental hardware of the cervical spine and debridement of the infected incision.
  • ICD-9 code 86.22 (excisional wound debridement) was reported on the claim.  

Error:

  • In this example the debridement is an integral component of the repair and should not have been reported separately.
  • Removal of this code resulted in a DRG change from 464 with a relative weight of 2.9406 to DRG 496 with a relative weight of 1.6306

Example 2:

  • The patient presented with liquefaction of fat necrosis of a knee wound.
  • ICD-9 Code 996.77 (Complication internal joint prosthesis) was reported as the principal diagnosis.
  • The operative note and Discharge Summary supported that the patient had liquefaction of fat necrosis of knee wound.
  • The reviewer found that per ICD-9 Guidelines for Hospitals and the available medical record documentation that the more appropriate principal diagnosis code was 998.89 (Other specified complication of procedures, not elsewhere classified (NEC)).

Error:

  • ICD-9 Code 996.77 was replaced with ICD-9 Code 998.89 due to documentation not supporting that the complication was due to the prosthetic knee.  
  • Adding insult to injury, this patient also did not meet medical necessity for an inpatient admission.

For Coding Clinic Guidance and Medicare Program Integrity Manual information supporting these findings, the entire post can be found on the Cahaba website under the Part A - What's New.

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc.  Beth has over twenty-two years of experience in healthcare including eleven years in Case Management at a large multi-facility health system.  In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare.  You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..
This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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