Wiki Irrigation/Debridement

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keke74

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Hello all,

Need help with coding of the below procedure. The documentation doesn't seem to support utilizing the debridement codes.

Procedure of the right shoulder was marked and confirmed as the operative site was then transferred the operative placed in supine position LMA was induced antibiotic prophylaxis was infused then prepped out of the right shoulder in usual sterile fashion we then examined the hole appeared to be significant breakdown resulting from the underlying tuberosity. There was no gross purulence noted there was scant serous fluid with expression. Fluid cultures were then taken we then made a longitudinal incision ellipsing out of the area of breakdown. We then copiously irrigated with pulse lavage after thorough irrigation we then placed vancomycin powder within the incision and then closed with a 2 0 0 Monocryl and a 2-0 nylon for the skin. We then placed a Prevena VAC dressing overlying the wound to help reduce wound tension.

Thanks in advance
 
The statement ‘made a longitudinal incision ellipsing out of the area of breakdown’ suggests that the provider may have removed nonviable tissue which would support a debridement code. But the excerpted documentation here is rather vague and it’s not completely clear what the provider is doing or why.
 
This is where you as a certified coder comes in. This documentation is incomplete. There are three basic body tissues: Skin/muscle/bone. The provider needs to specifically document what was the deepest tissue debrided or removed. That is missing. That is why you are having a difficult time coding this. Having said that, I don't think this would be coded from the debridement section. The patient has developed on open wound/ulceration which was closed. Debridement is almost always bundled with wound closure. Since the wound was closed I would look at those codes instead of debridement.
 
I agree the documentation you have here is too vague, was there more to this op note? Was this a post-op wound dehiscence or infection of a prior surgical wound? Was this a new, open wound from some sort of injury, was it an open fracture site? Was there a prior fracture of the tuberosity?
Could be a lot of options depending but this note doesn't have enough info. Code options could be 13160, 10180, 12020, 13120 (maybe repair depending). I agree it's most likely not the 97597 area.

This really sounds like a post-op type or post ORIF and a non-healing surgical wound. Are they a smoker or diabetic? Also, if they took cultures what did the results say, staph?
 
The procedure was an irrigation debridement of right shoulder with closure and overlying VAC placement for infection of prosthetic shoulder joint. I looked at 12020 & 13160 yesterday but in my opinion, neither of those appeared to apply to the documentation. In my opinion, the documentation appears incomplete. I was told that 11042 would apply here but again, I don't think the documentation supports coding from the debridement section. The above note is the full op note.
 
keke74 said:
The procedure was an irrigation debridement of right shoulder with closure and overlying VAC placement for infection of prosthetic shoulder joint. I looked at 12020 & 13160 yesterday but in my opinion, neither of those appeared to apply to the documentation. In my opinion, the documentation appears incomplete. I was told that 11042 would apply here but again, I don't think the documentation supports coding from the debridement section. The above note is the full op note.
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Yes, I think you need to send it back to the provider for clarification. Is the TSA or hemi in the global? Interesting there was no arthrotomy. It very well could be 11042 but you need a more specific and detailed note. There aren't even measurements or depth to be able to code debridement. It sounds like 10180 or 12020. But again, we are just guessing since the report is not great.
 
keke74 said:
The procedure was an irrigation debridement of right shoulder with closure and overlying VAC placement for infection of prosthetic shoulder joint. I looked at 12020 & 13160 yesterday but in my opinion, neither of those appeared to apply to the documentation. In my opinion, the documentation appears incomplete. I was told that 11042 would apply here but again, I don't think the documentation supports coding from the debridement section. The above note is the full op not
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Knowing this information initially would have helped us help you. FYI. I thought it could be an ulceration that developed, Amy thought it could have been dehiscence and it could have been either of these scenarios.
 
I just want to say that just because one may be a "certified coder" doesn't mean that you want need assistance from time to time. We all have our strengths and weaknesses. I have utilized this forum over the years for assistance and I have even contributed to some of the posts. I'm a team player and if I can be of help to someone, I have no problem sharing my knowledge. Thanks to all of you that have contributed to this post. Go Team!!! Have a great weekend!
 
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