Question: If an orthopedic surgeon documents an open fracture was debrided and copiously irrigated without giving the tissue type or depth, does the documentation support assigning an open fracture debridement code? The documentation doesn’t describe the tissue as contaminated or that the tissue was removed.
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Answer: If the physician’s documentation clearly states the patient has an open fracture and performed debridement, then that is all you need to report an open fracture debridement code, such as 11010-11012 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement) …).
You can request clarification or an addendum from the provider if the documentation doesn’t specify the depth and type of tissue, but it’s not necessary. Debridement in this case does not specify sharp or blunt instruments for the excisional debridement for the open fracture codes, nor volume of tissue debrided. Gross contamination is also not a prerequisite, as the bone is exposed to the outside environment, which requires irrigation and debridement.
Mike Shaughnessy, BA, CPC, Development Editor, AAPC
