Wiki Open Fracture Debridement Coding

[Jody Mortensen]

Hi, needing some help/education with handling of documentation for open fracture debridement & would appreciate any assistance, references you can give. If a surgeon documents an open fracture was debrided, giving to the depth of the tissue and copiously irrigated does this documentation support assignment of the open fx debridement codes 1101x? There is no documentation stating a description of the tissue as contaminated etc, that the tissue was removed - only the tissue was debrided & copiously irrigated. I believe the codes are for excisional debridement with more documentation needed in order to support an open fracture debridement code. If my thinking is correct & there was no update supporting as excisional debridement would another code be assignable? Thank you kindly

 

[NRaizman]

If there was clearly an open fracture, and they document debridement, that is all that is required. If they do not specify depth/type of tissue, you can ask for clarification or an addendum. There should be no other hoops to go through. Debridement here does not specify sharp/blunt nor excisional for the ope. Fracture codes, nor volume of tissue debrided. Gross contamination is not a prerequisite either - if bone is exposed to the outside environment, that is a bad, bad thing and requires irrigation and debridement. Antibiotics and irrigation are more important clinically than debridement, BTW.

Don’t make things harder for your surgeon. The bar is set low.
N