What You Need to Know: Querying for Procedure Specificity

I recently came across a denial indicating that a query was noncompliant because it did not include evidence why the query was needed. I was flabbergasted by the auditor’s denial, because the purpose of the query was to clarify the type of debridement performed by an orthopedist.

I guess I assumed that most auditors were familiar enough with the Official Guidelines for Coding and Reporting that they would know when a query is required for clarification. Those of us who worked in clinical documentation integrity (CDI) when ICD-9 was still in use remember that we frequently had to query providers to further clarify the type of debridement performed as excisional or non-excisional.

This query remains relevant today, but maybe doesn’t occur as frequently, because ICD-10-PCS allows the coder to assign a PCS code based on the documentation in the health record. Specifically, “the physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.”

In this example, the provider documented a bedside incision debridement with two longitudinal incisions. A hemostat was used to break down any loculations, and purulent material was expressed. The wound was irrigated with normal saline and packed with iodoform. Because excision is defined as “the cutting out or off, without replacement,” this documentation is somewhat ambiguous, because a hemostat was used to remove tissue, but there was an incision to get to the tissue.

The next step would be to see if debridement or incision debridement is indexed within ICD-10-PCS, as directed by coding guidelines. Debridement is in the ICD-10-PCS index, but requires further clarification as excisional (in which case the root operation is excision) or non-excisional (in which case the root operation is extraction) to assign a procedure code.

ICD-10-PCS does not include a default procedure code for debridement.

Because a code could not be assigned based on the description of the procedure nor documentation of “incision debridement,” it was appropriate to query the provider for clarification. This is supported by a 2015 Coding Clinic that stated, “a code is assigned for excisional debridement when the provider documents ‘excisional debridement,’ and/or the documentation meets the root operation definition of ‘excision’ (cutting out or off, without replacement, a portion of a body part).”

Additionally, the Guidelines for Achieving a Compliant Query Practice includes “to clarify the objective and/or extent of a procedure” as one of the reasons to query.

Now that I’ve established it was appropriate to query for clarification, let’s address the concern stated by the auditor that “queries must be accompanied by the clinical indicator(s)/evidence that supports a more complete or accurate diagnosis or procedure.” To me, it seems obvious that the inability to assign a code based on the current documentation for a valid procedure is sufficient evidence to justify a query – especially because there is coding guidance and query guidance to back up this perspective.

Additionally, the ICD-10-PCS Official Guidelines state, “the importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”

In my opinion, the fact that documentation of “incision debridement” is insufficient to assign a corresponding procedure code is the evidence that a more complete or accurate procedure can be assigned. I don’t know what additional documentation the auditor expected to see, as there are many times when a term used to describe a procedure must be clarified. In this example, the provider did discuss making an incision, breaking down loculations, and expressing purulent material.

The provider could have stated that they were performing an incision and drainage, but they specifically described it as “debridement.” They also documented a “wound” rather than an abscess, which is usually associated with an incision and drainage, even though drainage was part of this procedure.

The “when not to query section” of the query practice brief states, “do not query if the provider cannot offer clarification based on the present health record documentation.” Another reason not to query is “when there is insufficient documentation to assign a valid code and no indicators that the code can be specified to a higher degree.” Remember, the role of CDI is to clarify documentation that is vague, incomplete, or missing to support accurate code assignment.

Most providers are familiar with the term “debridement,” but the documentation requirements for code assignment are different for professional and hospital billing. Describing the procedure as “debridement” is sufficient to report a Common Procedural Terminology® (CPT) code, as long as it also includes the depth and surface area, which the provider did include in the procedure note. Most providers either do not know or don’t remember that ICD-10-PCS differentiates between excisional and non-excisional debridement, so it is not unusual for their documentation to reflect the requirements for CPT code assignment.  

To assist the orthopedist in further clarifying the type of debridement, the query included the definition of excision and non-excisional debridement within the response options. According to the Q&A section of the query practice brief, including definitions on a query is “common” and “not thought to be leading” as long as the information is provided without bias towards a desired response, which it was.

Lastly, the provider was given the opportunity to respond that they were unable to determine. Multiple-choice queries must include the option of “other” but are no longer required to include “unable to determine.” If the orthopedist could not further clarify the type of debridement as excisional or non-excisional, the provider could have chosen the response of “unable to determine.”

The reason the auditor provided to justify the removal of the procedure code is invalid. However, this scenario represents a new tactic being used by payors: removing a reportable procedure (or diagnosis) from a claim to justify a lower payment. In this scenario, removal of the excisional debridement procedure code reduced the payment by over $2,000, shifting the claim from a surgical MS-DRG to a medical MS-DRG.

As these types of denials become more common, it is imperative that healthcare organizations have denial professionals who not only understand coding guidelines, but also query guidelines. Additionally, some denials also require a clinical background to determine their validity. The CDI professional can be a great addition to a hospital’s denial management team, especially if CDI professionals are the ones who query for the organization.

Programming note:

Listen live this morning for the CDI report with Cheryl Ericson on Talk Ten Tuesday with Chuck Buck and Angela Comfort at 10 Eastern.