Wiki Debridement of finger

[ReignRuby]

I have assigned CPT 11042 to the op note below. I have not coded very many of these cases. Is this correct and covering everything the physician performed? Would this include the suture removal? I code for an ASC.

POSTOPERATIVE DIAGNOSES: Left index finger pain status post
complex nailbed repair/open fracture of distal phalanx and
laceration of repair.
PROCEDURES PERFORMED: Debridement of left index finger, removal
of deep sutures, ablation of nailbed, debridement down to the
bone.

I then made a longitudinal dorsal incision over
the distal phalanx/nailbed. Once through the skin, I did
encounter a small area of remnant nailbed, which was likely
causing discomfort as there tried to grow nails underneath the
skin. I excised this nailbed in its entirety and then also
cauterized the border to fully ablate it. I also removed three
deep sutures that were non-dissolvable at the attachment of the
extensor mechanism at the base of the proximal phalanx. I also
removed a deep Monocryl suture from the distal radial tip. I
also debrided significant amount of scar tissue. Once this was
done, I irrigated the wound and closed the skin dorsally using
interrupted 4-0 Prolene suture.

 

[Orthocoderpgu]

One hint that I can give you quickly is that anytime an incision is made the debridement codes 11XXX are off the table.

In the procedures performed the physician noted that there was debridement "down to the bone" but this is not supported in the body of the op note. The specific body tissue debrided needs to be documented in the body of the note. Was there debridement of the bone itself or did the physician stop at the bone but not debride the bone? The tissue structures that were debrided needs to be documented.