Wiki Help with CPT code - Sharp excisional debridement

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TMB1965

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Would this be CPT code 11042

Sharp excisional debridement right great toe wound was done.Right great toe was prepped with betadine and using # 15 scalpel and forceps excision of eschar was done. No bleeding Size of wound 2.0 X 1.0 cms X 0.4 cms.

Underneath tissue is healthy. NO bone seen.
Wound care with daily gentamicin cream and dressing.
 
Without knowing anything further

11042 would be correct; however if you can query the provider and find out if the debridement went further than the subcutaneous level. He may have gone down to muscle and facia.
 
Okay, thank you. Another thing I'm having a problem with is the diagnosis, because according to the LCD 785.4 is not a supported diagnosis, so can you tell me if there is another diagnosis I could use for this that's supported by the LCD? This is what the provider documented.


Follow up gangrene right great toe.

Right foot is fine. Right great toe tip gas receding dry gangrene eschar which is getting loose from sides. No drainage. Rest of foot and toes are fine.

Assessment:
Dry gangrene of distal right great toe.
 
You need an underlying cause for the gangrene, such as chronic disease or trauma to be coded first. You will need to query the provider.
 
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