Study: Debridement causes coding confusion
In a study surveying ICD-9-CM subcategories, debridement was found to be the subcategory that caused the most confusion among coders, based on a report published in the summer issue of Perspectives in Health Information Management.

Debridement can be performed on skin, muscle and bone in addition to other tissues. Appropriate ICD-9-CM code assignment depends on the documentation provided in the medical record.

“One source of the confusion surrounding this category is certainly that medical documentation is often not detailed or accurate enough to support coding as an excisional debridement case,” wrote authors Xiaoming Zeng, MD, PhD, and Paul D. Bell, PhD, both from East Carolina University in Greenville, N.C. As a result, they recommended it for further study aimed at improving coding accuracy and variation.

The researchers sought to determine problematic ICD-9-CM subcategories for future coding performance study. “With the increased promotion and adoption of EHRs in healthcare management and transactions, addressing the coding quality issue has become increasingly important," the authors wrote. “Therefore, guidelines directing the coding process need to be reviewed and updated consistently in order to reduce coders’ confusion and improve coding accuracy.”

The study, conducted in 2008, used qualitative research called the Delphi method. All communications in the study were through teleconference calls and e-mails with seven panelists who specialize in medical coding.

They determined three criteria to identify a problematic ICD-9-CM subcategory for further study. These were: cost, volume and level of coding. The Medicare Provider Analysis and Review (MEDPAR) of 2007 fiscal year data as well as suggestions from the experts were used to identify coding subcategories based on cost and volume data.

Confusion was almost half of the total 48.3 percent among the three criteria, the researchers found. “We received a list of 13 unique ICD-9-CM code categories from the panelists,” they wrote. “After two rounds of the Delphi process, the panelists agreed that there was no need to have another round of ranking.”

The final ranking was the average of the two orders—documentation and guideline. Excisional debridement was ranked as the ICD-9-CM code subcategory with the most confusion associated with it. The standard deviation of the rank order value was zero after round two, which showed that all the panelists agreed that the excisional debridement subcategory caused the most confusion during the coding process.

According to Zeng and Bell, the top three ICD-9-CM code subcategorieswere complications, congestive heart failure and excisional debridement. “During the final discussion, panelists pointed out that the complications subcategory is impractical to address because there is no designated guideline for it and the code could be dispersed throughout the entire code set. It was also pointed out that the guideline for the congestive heart failure subcategory is already being investigated at the Centers for Disease Control and Prevention in order to improve coding performance.”

The panelists all agreed that excisional debridement should be chosen as the candidate for further study, especially because it is number one in the confusion rate ranking.

Zeng and Bell noted some limitations of the study including the use of a small number of experts in determining the subcategory of the ICD-9-CM code set they need to study.

“The importance of certain code set subcategories will vary with changes in healthcare policies, reimbursement models, coding systems and recovery audit contractor regulations,” the authors concluded. “However, the methods of this study can be applied to future studies of specific code sets in medical coding, regardless of the types or versions of the code sets investigated. We suggest, then, that future studies designed to look at problematic code set categories should consider using the framework proposed in this study to systematically review and choose the specific subcategory for study.”