Wiki need help with code for debridement note

[ollielooya]

Hi, colleagues; after being away for some time returning in a new position, and need some CPT coding guidance. Here's an extracted chart note: This will probably be easy for those of you who deal with these procedures regularly.

LT great toe wound is suspicious for an infected gouty arthritis versus osteomyelitis.
Description of Procedure: After informed consent PAT was taken to operative suite & sedated by anesthesia service. LT foot was then prepped draped standard fashion. We then anesthetized the base of toe & following this explore the tip of toe wound. This clearly extended to distal phalanx which was gently debrided. Cultures were obtained & specimens were sent for biopsy. Dressing was applied following a counterincision on lateral aspect of toe where IV tubing was placed for drainage. Patient tolerated procedure well/discharged home in stable condition

No measurements are supplied.

I see debridement and then an incision for drainage. Are they both considered components in the debridement process, and if so, choices are in the 110XX code range? Also, might 10140 be a consideration?

 

[Orthocoderpgu]

Hmmm

Look at 20103.

I don't see an incision being made so it appears that the doc is exploring an open wound.

 

[ollielooya]

following up on your thoughts

Thanks for jumping in to help. Although it was very interesting to view the code range of 20100-20103 that you suggested this is not a wound resulting from penetrating trauma
so not sure if this would fit this particular scenario. Yes, there is wound exploration but there was that counter incision made for drainage and that's what prompted my request
for help. Still baffled...

 

[meghanhannus]

Debridement of distal phalanx bone

Hello ollielooya,

I believe this is debridement of the distal phalanx bone. I am thinking CPT 11044 for bone debridement.

CPT 11044: The physician surgically removes foreign matter and contaminated or devitalized bone (including epidermis, dermis, subcutaneous tissue, muscle, and/or fascia, if performed) caused by injury, infection, wounds (excluding burn wounds), or chronic ulcers. The physician uses the appropriate surgical instrument (i.e., scalpel) to excise the affected tissues into the bone. Depending on wound size, closure may be immediate or delayed. The wound may be packed open with gauze and require immediate or delayed reconstruction.


Hope this helps

M.Hannus, CPC, CPMA, CRC