Discharge diagnosis documented as congestive heart failure and benign . According to the UHDDS, if more than one procedure meets the criteria for Per ICDCM Official Coding Guidelines who may perform excisional debridement?. Documentation requirements to support excisional debridement coding are According to the ICDCM Official Guidelines for Coding and. All too often, an excisional debridement is coded when the procedure documentation meets the definition ICDPCS Official Coding Guidelines specifies.
No intraoperative x-rays were needed for confirmation due to the extent and penetration. No exudate was noted. No drainage of purulence was expressed.
Coding, Classification & Reimbursement
No fluctuance was noted. Following debridement, as stated above, the wound was reverse scrubbed and dressed with Betadine-soaked dressing and dry sterile dressing. Attention directed to the second toe on left foot, where necrotic eschar encompassing the entire tip of the second toe was noted.
With fresh 10 scalpel blade, all necrotic devitalized tissue was noted. However, the toe had curled toe deformity consistent with remaining digits of left foot from 2 to 5. No bone was truly noted through the ulcer defect and it was elected not to proceed with amputation of tip of the toe, rather just debride with a curette and rongeur, and all devitalized tissue was removed as well.
Coding Clinic for CDI:Reassessing debridement documentation - pdl-inc.info
Reverse scrub was performed on the second toe left foot and no abscess was noted. Minimal bubble swelling was noted and had been diminished since the time of admission. Attention was then directed to the plantar aspect of the first MPJ of the left foot, where a 1-cm ulceration was noted. Using another set of 10 scalpel blade and rongeur, the area were debrided of all devitalized tissue. There are times when a physician may need to clean an area for a procedure or perform an excisional debridement that is not integral to the procedure itself.ICD-9-CM General Coding Guidelines for Procedures
In such cases, the documentation in the medical record needs to be as clear as possible regarding what the physician did and why he or she did it.
If a cleaning was performed as part of an overall procedure, it may not be coded separately.
Coding, Classification & Reimbursement - American Health Information Management Association
However, if a provider performs a true excisional debridement, it could require separate code assignment. Excisional debridement is considered a surgical procedure that results in a surgical MS-DRG and a higher relative weight, which translates into a higher reimbursement. Root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to scalpel, wire, scissors, bone saw, and electrocautery tip.
Elements that must be documented in the medical record to support an excisional debridement include: Technique used by the provider cutting, scrubbing, trimming Instruments used scissors, scalpel, pulse lavage, or curette Nature of the tissue removed slough or necrosis, devitalized tissue, or non-viable tissue Appearance and size of the wound fresh bleeding tissue or viable tissue Last but not least, the physician needs to document the depth of the debridement.
This makes remembering all the information needed for appropriate code assignment a little easier. Excisional debridements can be performed by nurses, therapists, physician assistants, or physicians, and must be documented as such by the person who performed the debridement. An excisional debridement can be performed in many areas in a facility.