Inpatient Facility Coding & Compliance Alert

Question: The physician documented excisional debridement in the inpatient progress note – nothing else. Do we report diagnosis 86.22?

Mississippi Subscriber

Answer: Diagnosis 86.22 (Excisional debridement of wound, infection, or burn) might not always be the most appropriate code for the situation.

For example, if the physician documents debridement down to and including muscle and bone, you wouldn’t report 86.22. You would choose a more appropriate code for debridement of the bone instead, such as from the 77.60-77.69 (Local excision of lesion or tissue of bone) sequence. Code 86.22 also would not be appropriate if the physician documented using a scalpel to perform debridement down to and including muscle which would move you to 83.45 (Other myectomy).

Remember: Never code solely from the title of an operative report, or even from the initial notes. Always validate exactly what procedure the physician performed by reading the body of the operative report or note. If you aren’t able to validate information, query the physician for clarification.