Wiki Is 11042 Debridement skin/sub-q tissue correct for this scenario?

[Nabelle]

Pt returned to see MD for some purulent drainage coming from around a full-thickness skin graft. Provider examined the area…full-thickness skin graft appears to have epidermolysis and underneath appears to be healing soft tissue and skin. The drainage was coming from the graft and using a scalpel and then pickups, the skin graft was debrided from the purulent area and it was noted to have intact and viable soft tissue and skin beneath the skin graft. Proximally, 60% of skin graft was debrided and 40% remained and left intact. The wound was irrigated and a soft dressing was applied.



I am recommending 11041 Debridement; skin, full thickness. I have a feeling that neither of the codes is right. Looking for the correct DX also... provider reported 998.59. I'm leaning towards 996.69. HELP!

 

[FTessaBartels]

998.59

As for 11041 vs 11042 I'm thinking 11041 ... but would really want to see the actual op note to be sure. It's possible that some sub-Q tissues was also debrided.

I would agree with doctor on 998.59 - Other postoperative infection. A skin graft is NOT an implant or "internal prosthetic device."

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[Nabelle]

Since payor is Medicare... do you think this visit is inclusive to the global surgical package?

Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room.

I apologize for not stating this "visit" occured in an office setting and not in the OR.

Appreciate feedback