Excisional Debridement
Good morning.
Patient was admitted with a pressure injury to the right hip and underwent debridement.
My question is:
Will this documentation by the surgeon be coded as excisional?
I have received different answers and I need some help deciding to query or not to query.
"...Endocrine overlying eschar over the wound was completely taken down using sharp dissection with the scalpel and cautery....The necrotic tissue extended down to the level of the overlying muscle fascia and included some areas of the fascia which were all sharply debrided...."
Thank you for taking your time to review.
Lissette
Patient was admitted with a pressure injury to the right hip and underwent debridement.
My question is:
Will this documentation by the surgeon be coded as excisional?
I have received different answers and I need some help deciding to query or not to query.
"...Endocrine overlying eschar over the wound was completely taken down using sharp dissection with the scalpel and cautery....The necrotic tissue extended down to the level of the overlying muscle fascia and included some areas of the fascia which were all sharply debrided...."
Thank you for taking your time to review.
Lissette
Comments
According to this coding clinic looks like you should query. Not sure if there is anything more recent.
Coding Clinic 3Q2015, p3
Question: Can you clarify what determines that a debridement in ICD-10-PCS is excisional? The progress note states: “I have debrided the abscess cavity, removing necrotic tissue and bone by sharp debridement.” Does the word “excision” need to be present as with ICD-9-CM?
Answer: Yes, the documentation standard for coding excisional debridement in ICD-10-PCS is the same as it is for ICD-9-CM. As with ICD-9-CM, the words “sharp debridement” are not enough to code the root operation Excision. A code is assigned for excisional debridement when the provider documents “excisional debridement,” and/or the documentation meets the root operation definition of “excision” (cutting out or off, without replacement, a portion of a body part).