Orthopedic Coding Alert

Question: The orthopedic surgeon is treating a patient with an open transverse radial shaft fracture. Before performing the repair, the provider cleans the skin around the injury, then debrides the foreign material and necrotic tissue that has built up due to the injury. Using a scalpel, she then removes injured tissue in and around the site of the fracture. Then, the orthopedist irrigates the tissue layers before performing open treatment of the fracture with internal fixation. How should I report this encounter?

Florida Subscriber

Answer: You should report a code for the fracture treatment as well as a code for the debridement. On the claim, report 25515 (Open treatment of radial shaft fracture, includes internal fixation, when performed) for the fracture treatment. Be sure to append S52.32- (Transverse fracture of shaft of radius) to 25515 to prove medical necessity for the procedure.

Then, report 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) for the debridement. Choose the most descriptive diagnosis code you can based on the notes; from your description, the best choice is S61.50- (Unspecified open wound of wrist).

Note: Patients suffering from fractures will often also need wound cleaning or debridement for their injuries, especially if they have the injuries occurred in some sort of accident. From your description of the provider’s actions, 11010 is the best debridement code for your encounter.

There are some other debridement codes you might consider in these situations as well; if the situation warrants, you might choose 11011 (… skin, subcutaneous tissue, muscle fascia, and muscle) or 11012 (… skin, subcutaneous tissue, muscle fascia, muscle, and bone) instead of 11010. In every fracture/debridement claim, choose the debridement code that most closely describes the encounter.