solocoder
Expert
Is there any way this debridement is billable to Medicare, and not considered a complication? Is there something I'm missing? Or something the doctor could clarify?
Patient had a toe amputated. Post op visit reads:
Left great toe amputated. Fibrous slough noted to wound base. Upon debridement of amputation site ulcer with fat layer exposed measuring 1.5x 0.8 x 0.2 cm noted. Healthy bleeding noted on debridement. No erythema noted. No malodor noted. Mild edema noted to foot. Able to dorsiflex, plantarflex, invert, and evert foot without difficulty. Skin temperature is warm to palpation. Strong DP pulse noted.
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Debridement:
Type- ( x ) Excisional ( ) Non-excisional
Instrument- ( x ) Scalpel ( x ) Scissors & Forceps ( ) Curette
Tissue removed- ( x ) Skin ( x ) Subcutaneous ( ) Muscle
Appearance- ( x ) Fresh bleeding tissue ( x ) Viable tissue
Nature of tissue removed-- ( x ) Slough/biofilm ( x ) Non viable tissue ( ) Necrosis
Size- Pre 1.4 cm x 0.5 cm x 0.1 cm Post 1.5 cm x 0.8 cm x 0.2 cm
Depth- ( ) Limited to breakdown of skin (x ) Fat layer exposed
( )Necrosis of muscle ( ) Necrosis of bone
Patient had a toe amputated. Post op visit reads:
Left great toe amputated. Fibrous slough noted to wound base. Upon debridement of amputation site ulcer with fat layer exposed measuring 1.5x 0.8 x 0.2 cm noted. Healthy bleeding noted on debridement. No erythema noted. No malodor noted. Mild edema noted to foot. Able to dorsiflex, plantarflex, invert, and evert foot without difficulty. Skin temperature is warm to palpation. Strong DP pulse noted.
*
Debridement:
Type- ( x ) Excisional ( ) Non-excisional
Instrument- ( x ) Scalpel ( x ) Scissors & Forceps ( ) Curette
Tissue removed- ( x ) Skin ( x ) Subcutaneous ( ) Muscle
Appearance- ( x ) Fresh bleeding tissue ( x ) Viable tissue
Nature of tissue removed-- ( x ) Slough/biofilm ( x ) Non viable tissue ( ) Necrosis
Size- Pre 1.4 cm x 0.5 cm x 0.1 cm Post 1.5 cm x 0.8 cm x 0.2 cm
Depth- ( ) Limited to breakdown of skin (x ) Fat layer exposed
( )Necrosis of muscle ( ) Necrosis of bone