Wiki Wide excision of ulcer

here's the report
the patient had general anesthesia, 2 cm was marked around the area in a circular fashion. The area was was removed with 2 cm rim all the way down to the fascia of the right extremity. the mass was removed and sent to pathlogy for permanent sectioning. Excellent hemostasis was noted. The area was packed with 4x4 and the wound was dressed with kerlix and then ace bandage.

dx- was chronic nonhealing right lower etremity ulcer.
procedure -was wide excision of area
pathalogy report - non healing leg ulcer- dx code 707.9
 
ulcer

I too would use the debridement codes, but the physician will have to give more documentation. The size, depth, stage etc., and I would also use the 707.10 instead of the 707.9 as the location is listed as leg.
 
I agree that it sounds like more of a debridement too, however I would be cautious since he did state "wide excision of MASS". I would get this clarified. The depth of the debridement is in the note and indicated as "all the way down to the fascia" so you wont need to find out the depth. The size wont be an issue if this is a debridement as those codes are not size related.
 
Not be the devil's advocate here but I do not get the impression this was a debridement at all, I would either go to excision of soft tissue mass which codes out as removal of tumor by anatomic sie ot to incision of soft tissue abcess deep. He did not just remove devitalized tissue he excised the mass which was sent to path and determined it was an ulcer. Just a thought
 
What if the physician debrided skin, subQ and tendon? He believes it should at least be a 11043 but he did not remove any muscle tissue.
 
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