# wound debridement



## lindacoder (Jun 14, 2018)

patient presented with necrotizing fascitis. This is the first of three surgeries performed.  Dictation states to fascia and muscle.  I would love to use CPT 11004 11005 but it is not for extremities.  I am  not sure how to break down 11043 and 11046 to get to 120 cm.  Any suggestions would be appreciate.

PREOPERATIVE DIAGNOSIS:  Left arm abscess with concern for necrotizing soft  tissue wound.
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POSTOPERATIVE DIAGNOSIS:  Left arm necrotizing soft tissue wound.
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PROCEDURE:  Left arm wound exploration measuring 25 x 10 x 4 cm with  debridement of subcutaneous tissue and wound VAC placement.
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ANESTHESIA:  General.
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SPECIMENS:  Wound culture to microbiology.
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ESTIMATED BLOOD LOSS:  Less than 50 mL.
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FINDINGS:
1.  Small area of necrotic fat at the medial aspect of the left antecubital  fossa and the area of gas collection on CT scan.
2.  Diffuse edema throughout the soft tissue.  No evidence of tracking  infection along the fascia.
3.  An area of induration to the contralateral arm (right arm antecubital  fossa) was noted after the patient was then anesthetized.  This was not  fluctuant and no acute evidence of abscess.  This is concerning for potential  site of skin manipulation.
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INDICATIONS FOR PROCEDURE:  The patient is a 31-year-old female who presented  with severe onset of left arm pain over the past 48 hours.  CT was obtained  which revealed a gas collection at the medial aspect of the arm which was  concerning for possible early necrotizing fasciitis.  She had diffuse pain and  edema to the upper and lower arm.  Given these findings, surgical intervention  was indicated.  The risks, benefits and alternatives of procedure were  discussed with the patient and she wished to proceed.
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DESCRIPTION OF THE PROCEDURE:  The patient was taken to the operating room  theater.  She was placed in supine position.  General anesthesia was induced.  Preoperative antibiotics were administered.  The patient's left arm was then  prepped and draped in normal sterile fashion.  A lazy S incision was made  along the medial aspect of the upper arm and then extending laterally in the  lower arm.  This was done to be able to access the area of greatest concern  with the gas collection along the medial aspect near the antecubital fossa.  Dissection was carried down with electrocautery.  There was diffuse edema that  was then expressed immediately with the incision through the subcutaneous  tissues.  A combination of blunt and sharp dissection was utilized.  She has  an area of a necrotic-appearing fat at this medial aspect of the area of  greatest concern on CT scan.  There was diffuse edema to the subcutaneous  tissue, but no evidence of infection tracking along the fascial compartments.  The fascia overlying the biceps in the upper arm was opened.  There was no  significant muscle bulging or evidence of pressure within this compartment.  This was done likewise in the forearm and again all the edema was within the  subcutaneous tissue and no evidence of excessive pressure within the muscular  compartments.  Hemostasis was achieved.  With dissection of this involved area  of concern, the proximal aspect of the cephalic vein in the forearm and in the  distal aspect of the basilic vein in the upper arm were both exposed.  There  was no soft tissue to be able to close over these.  Given this fact, after  hemostasis was assured and then it was clear that all infectious process had  been debrided and wound cultures have been obtained, an Adaptic was placed to  the wound bed and wound VAC then applied.
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The patient tolerated the procedure well.  There were no complications.  All  counts were correct as reported to me at the end of the case.
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## tcooper@tupelosurgery.com (Jul 24, 2018)

*Debridements*

4 Comments
Dig Deep into Debridement
Shed damaging coding habits and promote healthy reporting of wound debridement procedures.
Wound debridement is a medical procedure that removes infected, damaged, or dead tissue to promote healing. Debridement is generally associated with injuries, infections, wounds, and ulcers. To better understand how to code properly for wound debridement, let’s first look at why debridement is performed, and how it’s accomplished.

Wound Debridement

CPT® codes 11042-11047 describe the work performed during wound excisional debridement. An excisional debridement can be performed at a patient’s bedside or in the emergency room, operating room (OR), or physician’s office. Some key elements to look for in the documentation are:

The technique used (e.g., scrubbing, brushing, washing, trimming, or excisional)
The instruments used (e.g., scissors, scalpel, curette, brushes, pulse lavage, etc.)
The nature of the tissue removed (slough, necrosis, devitalized tissue, non-viable tissue, etc.)
The appearance and size of the wound (e.g., fresh bleeding tissue, viable tissue, etc.)
The depth of the debridement (e.g., skin, fascia, subcutaneous tissue, soft tissue, muscle, bone)
To determine the proper code choice, first consider the depth of the debridement. This is determined by the deepest depth of removed tissue. Keep in mind the wound may extend to the bone, but if only subcutaneous tissue is removed, the depth of debridement is to the subcutaneous tissue only.

Wound Surface Biofilm, Epidermis, Dermis 

97597 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

+97598
each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

Subcutaneous Tissue 

11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

+11045
each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

Muscle or Fascia 

11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

+11046
each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

Bone

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

+11047
each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

When debridement is performed to the same depth on more than one wound, the surface area of the wounds is combined. When the depth is different for two or more wounds, each wound is coded separately.

The second aspect of picking the proper wound debridement code is determining the surface area of the wound. If the entire wound surface has been debrided, the surface area is determined by the square centimeters (sq cm) of the wound after the debridement has been completed. If only a portion of the wound is debrided, report only the measurement of the area actually debrided.

Example 1: A patient with a 4 cm x 4 cm ulcer on his calf requires debridement of necrotic subcutaneous tissue. After the debridement is complete, the area measured 5 cm x 5 cm. Because the whole area was debrided, we code based on the final measurement of 5 cm x 5 cm (25 sq cm).

The codes for this case are 11042 and 11045.

Example 2: The same patient has a 4 cm x 4 cm ulcer on his calf, but over half of the ulcer was healing. The surgeon states that she debrided necrotic tissue on a 1 cm x 1 cm section. Code selection is based on the 1 cm x 1 cm section (1 sq cm).

The code for this case is 11042.

Example 3: The patient was in a motorcycle accident and has several abrasions on both arms, but no broken bones. The wounds are: left forearm 3 cm x 3 cm (9 sq cm); right shoulder 2 cm x 2 cm (4 sq cm); and right forearm 6 cm x 5 cm (30 sq cm). The patient is taken to the operating room and the surgeon performs a debridement of skin, subcutaneous tissue, and muscle in all three wounds. Because all three wounds are debrided to the same depth, we add the size together to determine the correct CPT® code(s).

The codes for this case are 11043 and 11046 x 2.

Wound Care Management

The CPT® codebook directs us to use the Active Wound Care Management codes 97597-97598 for debridement of the skin (i.e., epidermis and dermis only):

97597 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

+97598
each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

Notice the description states “selective debridement,” verses “non-selective,” as captured by 97602 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session.

Selective debridement is the removal of non-viable tissue, with no increase to wound size and typically no bleeding because the tissue removed is non-viable. Non-selective wound debridement is usually done by brushing, irrigation, scrubbing, or washing of devitalized tissue, necrosis, or slough. In non-selective wound debridement, the focus goes beyond the non-viable tissue.

Example 1: The patient has a pressure ulcer. The physician examines the ulcer and uses a pressure waterjet to debride the skin and eschar from the wound. The wound is left open to continue healing. This is an example of selective wound care, 97597-97598.

Example 2: The patient comes into the wound clinic for treatment of an open wound on the left thigh. It’s noted the deeper layers of the wound are healing very well. The provider uses a brush to scrub and wash the wound, removing all nonviable skin. The provider then dresses the wound with non-adherent gauze. This is an example of non-selective wound care, 97602.

Fracture Debridement

Fracture and Dislocation Debridement codes 11010-11012 are  based on the depth of the tissue removed, and whether any foreign material was removed at the same time.

11010 Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues

11011 skin, subcutaneous tissue, muscle fascia, and muscle

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

Repeat debridement may be necessary in certain circumstances. When coding for a “staged” or “planned” debridement during the usual postoperative follow-up period of the original procedure, it’s important to use the appropriate modifiers.

Use modifier 58 Staged or related procedure or service by the same physician or qualified health care professional during the postoperative period in the following instances:
When the debridement procedure(s) are staged prospectively at the time of the original procedure, or during the usual postoperative follow-up period of the fracture treatment.
When the staged procedure is more extensive than the original procedure. For example, when an initial debridement procedure(s) is performed and a larger procedure (e.g., definitive open fracture treatment) is a staged surgical intervention.
When other reconstructive procedure(s) (e.g., skin graft, myocutaneous flap, vessel graft) are planned or staged prospectively at the time of either the original procedure or during the usual postoperative follow-up period of other reparative procedure(s) and/or fracture treatment.
Example: The patient was in an automobile accident and sustained an open fracture of the left femur. On the day of the accident, the patient was brought to the OR and the open fracture was debrided of all necrotic tissue and debris. Under fluoroscopic guidance, the surgeon was able to manipulate the bone to create an ample reduction. An external fixator device was used and a dressing was applied to the open area.

Two days later, the patient was returned to OR and the dressing is removed. The surgeon examined the open fracture and irrigated the wound with saline. An area of 3 cm x 4 cm was dark and dusky looking. The subcutaneous tissue and skin was excised with a #15 blade to bleeding tissue. Some nonviable muscle tissue was also debrided. The area was then copiously irrigated and a dressing was placed.

Coding for the second debridement is 11011-58.

Hope this helps.
Teresa


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