Wiki Irrigation & Debridement

[djnall]

I am auditing this OP report/coding summary and am wondering about the irrigation. Physician wants 11012 coded. Here's the scrubbed OP note:

Diagnosis: Open left fracture, weight bearing surface tibia and fibula.

Procedure: "...The sutures for the wounds were removed and thorough irrigation was performed of the open fracture again. Attention was then taken to the fibula and incision was made appr. 15 cm in length. Care was taken to avoid damage to superficial peroneal nerve. the fracture was reduced and there was a butterfly fragment which was keyed into place..."

He then goes on to describe the fracture repair.

Is there enough documentation to support 11012?

Thanks in advance.

 

[Jamie Dezenzo]

Ortho Coding Alert,2009; Volume 12, Number 6

Per Ortho Coding Alert article:

Step 3: Check for Separately Codeable Debridement

Consider debridement a separate procedure only when gross contamination requires prolonged cleansing, and documentation must support that an appreciable amount of devitalized or contaminated tissue is removed or carried out separately without primary closure. Report debridement for these conditions with: 11040 (Debridement; skin, partial thickness) and 11044 (Debridement; skin, full thickness).

If the fracture is open, it may be necessary to clean and prepare the fracture prior to any restorative treatment and/or stabilization of the bone. The wound site may be contaminated with foreign material such as glass, dirt, grass, metal, gravel, etc. Open fracture debridement is separately reported under these circumstances and reported with 11010 (Debridement including removal of foreign material associated with open fracture and/or dislocations; skin and subcutaneous tissues) and 11012 (... skin and subcutaneous tissues, muscle fascia, muscle, and bone).

Hope this helps