# Open Fx Debridement - If a patient's wound



## kibbit99 (Sep 29, 2009)

If a patient's wound was closed from the open fracture and came back to re-explore the wound/debride, can you still billl the open fracture debridement range 11010-11012?  Or do you bill the normal debridement range 11040-11044?

It is still associated, so I am thinking the open fracture range?  

Thanks,

Kim


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## mitchellde (Sep 29, 2009)

I would go with the 11040-11044 range.  The fx debridement codes are for cleanng foriegn material and tissue from the fx site.  The fx has been repaired now and it is a post op wound.  Use the appropriate dx codes and you will be fine.


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## mbort (Sep 30, 2009)

The fracture debridement codes 11011-11012 MAY be used for follow up debridements in some instances.  Here is a CPT asst that may help you:

*Year: 1997 

Issue: March 

Pages: 1 

Title: Close-up look at the New Fracture Debridement Codes 

Body: In 1993, all open fracture codes in CPT were deleted. In short, the codes that existed before 1993 identified the type of fracture treated and not the type of treatment.

At that time, the debridement codes in the Integumentary section of CPT (codes 11040-11044) were the only codes available to physicians to represent their services. Historically these codes were used to report lesser debridement procedures, including stasis ulcers, superficial infected wounds, avascular tissue, gangrene, and other conditions.

These codes did not adequately describe debridement of more extensive injuries such as open axial or appendicular skeletal fractures, with tendon, ligament, vessel, or nerve injuries. Additionally, physicians needed a way to report treatment of soft tissue devitalization, degloving injuries,and extensive foreign body contamination.

Addressing Wound Exploration

The recent creation of the wound exploration codes addressed some services such as the removal of foreign material in the wound and the surgical extension of the dissection to determine penetration. However, these codes did not address the need to report the preparation of tissue for grafting and other procedures necessary to prepare a site for repair. In addition, the wound care codes could not be used to report definitive repairs on major structures, vessels, nerves, or tendons. Thus physicians had to use the specific repair code to describe the work performed (see CPT Assistant Vol 6, Issue 6, 1996, Using the New Wound Exploration Codes).

Extensive Debridement Procedures

CPT 1997 saw the incorporation of a set of codes (listed below) to more accurately represent extensive debridement procedures (beyond codes 11040-11044). These new codes can be used to report services provided in preparation of treating an open or closed fracture (eg, to address the debridement of injuries sustained from blunt or penetrating trauma, motor vehicle accidents, and sports and recreational activity accidents).

11010Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues

11011skin, subcutaneous tissue, muscle fascia, and muscle

11012skin, subcutaneous tissue, muscle fascia, muscle, and bone

Use of the New Fracture Debridement Codes

In order to report the new codes, physicians must perform extensive services and meet other criteria as well. Since there are other procedure codes (eg, wound exploration, fracture care) associated with these codes, it is important to discuss in detail the following:

•    when to use the fracture debridement codes;

•    with which services these codes may or may not additionally be reported; and

•    when to use modifiers.

Types of Fracture Debridement

The three new codes address the fracture debridement procedures, not the type of fractures involved. They are intended to address treatment of a number of injuries that require extensive preparation in order to adequately repair a wound site, including both open and closed fractures, and usually involve numerous layers of flesh and bone. Often more than one injury (and more than one injury type) exists that requires multiple debridement procedures. The type of treatment depends on the type of fracture that exists, and the number of injuries present.

Review of Open Fractures

Open fractures are those in which the bone and/or joint is exposed to the external environment, or a fracture or dislocation caused by a blunt or penetrating force sufficient to disrupt or penetrate skin layers, subcutaneous tissue, muscle fascia/muscle, and bones or joints. The site of the wound is often contaminated with foreign material (eg, grass, twigs, dirt, oil, grass, gravel, etc) and bacteria. The wound site may also involve the surrounding neurovascular structures, ligaments, and/or tendons, or involve dead or devitalized tissue, hemorrhaging, or swelling.

Review of Closed Fractures

Closed fracture wounds have no bones or joints exposed to the external environment and do not involve open wounds. These fractures and dislocations are caused by direct or indirect force. Some closed fractures may have associated skin contusions, deep abrasions, burns, and cutis separation from subcutaneous tissues (separation of the skin layers), may require fracture debridement.

Using the New Codes

Both open and closed wounds may require debridement beyond that previously represented by the debridement codes. Therefore, treatment of both types of wounds may be reported with the new codes, which were created to identify intensive procedures performed by a physician in order to effectively address the damage presented.

The new codes incorporate a number of procedures and can be staged or coded multiple times to indicate separate sites of fracture debridement or a separate service. Included as part of the service are: prolonged cleansing of the contaminated site; removal of all foreign/dead material from the wound site; and irrigation of all tissue layers and exploration of the soft tissue injured (including neurovascular, ligamentous, and tendinous structures).

The reason for performing these procedures is to leave behind viable tissue that may or may not be closed, and to reduce the amount of hemorrhaging and swelling usually associated with these types of wounds. In addition, there are some procedures that are performed concurrently with the debridement procedure (ie, obtaining cultures, antibiotic treatment, irrigation, wound management, and stabilization of the open fracture).

Multiple Debridement Procedures

Extensive debridement procedures can be performed multiple times during a session, depending on the circumstances. Some fractures can be corrected with a single fracture debridement procedure and reported with a fracture care code. Others may require multiple debridement procedures, due to the severity and extensiveness of the number of injuries involved.

In addition, some procedures that require more than one fracture debridement procedure on the same wound area, may be staged. In each of these circumstances, the correct code(s) depends on the particular service performed.

Reporting Multiple Debridement Procedures and Using Modifiers

Accidents and injuries occur under various conditions. In some cases, when multiple injuries occur, it may be necessary for the physician to perform multiple procedures to restore lost functioning. In these cases, you must be careful to accurately identify and report all of the work involved. Often times the way to do this is through use of modifiers (-51, -58, -78). Procedures requiring more work than the singular procedure code indicates require separate identification and rationale to correctly report the sum of the procedures performed.

Using the -51 Modifier

Multiple fracture debridement procedures may be performed when more than one injury exists. The wounds may be of the same type (requiring one code reported multiple times) or varying degrees, and involve different thicknesses of skin, subcutaneous tissue, muscle, fascia, or bone. The injuries may require different procedures, such as in trauma patients with combination wounds (wounds without fractures and open fractures located in different anatomical sites). In addition, it is not uncommon to treat a wound in which nerve, tendon, ligament, or vascular repair may be necessary in order to completely address the total injury involved.

When any other service is performed at the same session by the same physician you should report it by using the -51 modifier, which identifies multiple procedures performed during the same session. When a physician performs a single fracture debridement procedure, it is unnecessary to use a modifier.

Using the -58 Modifier

Some injuries require multiple fracture debridement procedures in order to correct the afflicted area. This is called staged fracture debridement. Staged debridement (to remove devitalized tissue and foreign material) can be used to address open fractures that have not yet been treated to accommodate the reduction of the bones or the dislocation involved. It can also be used to address tissue work that may have been delayed and performed later, after the debridement operative procedures, depending on the degree of contamination and the condition of the soft tissues. In either case, both methods require a repreparation and redraping process to insure the aseptic environment necessary to appropriately reduce the fracture or dislocation involved.

When performing a staged procedure, an initial fracture debridement may be performed for surgical extension of the skin wound to provide a complete exploration of the soft tissue, or for excisional debridement and irrigation of all tissue layers (this initial stage may last one or two hours).

Repeat debridement may be required for a heavily contaminated area or a wound that contains a large amount of foreign material (in this case, the initial debridement is followed at a later time by definitive fracture treatment). This stage can also be performed to identify the extent of a skin injury or determine the severity of a fracture. The level to which the surrounding nerves, vasculature, ligaments, or tendonous structures are involved may be determined. The procedure can be repeated to stabilize the wound for a later treatment in the postoperative period.

In any of these circumstances, the debridement procedures may be repeated as often as necessary to obtain a clean wound before, during, or after the appropriate fracture treatment. For staged procedures, report modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to indicate the circumstances of the service performed.

Using the -78 Modifier

There are some instances when a fracture requires additional treatment after an initial reduction, such as infections that develop (requiring drainage), reductions of dislocations, removal of hardware (pins, screws, plates, etc.), or to re-reduce a fracture. In these circumstances, it would be appropriate to identify these procedures by appending the -78 modifier (return to the operating room for a related procedure during the postoperative period).

Summary

Since debridement procedures include both exploration for damage and the debridement procedure, it is important to differentiate the use of these codes from other related codes (nonfracture debridement, wound exploration).

There are a number of circumstances when fracture debridement codes could be reported. Although they are usually used to prepare the wound site for the definitive reparative work, the debridement protocol is also performed to reduce the potential for complications that can jeopardize limb survival, particularly in the polytraumatized patient.

In extreme cases, this procedure limits the possibility of developing a life-threatening injury (eg, the development of sepsis, embolism, gangrene, etc). The service can be provided as a separate service (no modifier necessary) or performed in conjuction with some other type of service (such as open/closed fracture care). The provision for this type of service may also require multiple stages to address the injury. In these situations, it would be correct to assign the appropriate modifier(s) to identify the specific circumstances that exist.


Â© 2005 American Medical Association
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## mitchellde (Sep 30, 2009)

mbort said:


> The fracture debridement codes 11011-11012 MAY be used for follow up debridements in some instances.  Here is a CPT asst that may help you:
> 
> *Year: 1997
> 
> ...



Thanks Mary!  I did not have this one in my bag of goodies I so appreciate the reference!


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