Wiki Debridement "Down To"

[MI_CODER]

Hello,

How are you guys coding debridements when the documentation states "down to"?

Findings: Frankly necrotic tissue extending along the left buttock with tunneling down to the level of the muscle. Cautery excisional debridement performed down to healthy tissue at the level of the muscle.

Cautery excision was performed circumferentially around the area of concern, involving frankly necrotic tissue, and extended down to the level of the muscle. Bleeding was noted along the skin edges and within the cavity. The excised tissue was removed from the surgical field to be sent for culture. Debridement size of wound: 10 cm x 11 cm x 5 cm down to the level of muscle.

Would this be coded as 11042, 11045 x 5 or 11043, 11046 x 5?

Thanks in advance.

 

[Orthocoderpgu]

My vote would be 11042. Per the documentation your provider "arrived at" the muscle, but did not necessarily debride it.

 

[MI_CODER]

That's how I was looking at it too. Thank you!

 

[amyjph]

Agree. Could have a feedback discussion or CDI improvement tip with provider to possibly use different words and indicate exactly what was debrided. In some instances I have seen that they actually mean they debrided muscle it is just not explained well. Debridement is one of the most annoying things to code! At least you have the measurements in that one.