The problem that your having is the documentation. Can a separate open wound be billed for that is not in the same surgical area of the amputation? Of course. However your provider has not documented this specifically. The provider states that the necrotic wound was at the base of the toe. Well, that's at the MTP joint which is where the incision was made to remove the toes. In the 6 X 5 debridement, does that include the debridement of the MTP joint? My guess is yes, but that debridement is part of the amputation procedure and would not be reported separately. If there was a separate open wound, what tissue depth was debrided? You don't know because it's not in the body of the op note. Your provider has lumped all information for the debridement on one line that's not even included in the body of the note. As documented, you would not be able to report debridement separately. I'm not saying that it was not performed and not billable, I'm just saying the way the documentation reads, the debridement seems to be in the same area as the amputation and not a separate area of treatment. In foot & ankle providers have to be very specific in their documentation.
