Important coding updates, documenting debridement

With the implementation of ICD-10, there is an increased need to document specific details related to many diagnoses, including adding additional information for cases in which debridement is done.

Here are a few hints to help ensure the accurate clinical coding of excisional debridement:

1. Debridement vs. excisional debridement per ICD-10:

“Debridement of the skin and subcutaneous tissue is a procedure by which foreign material and devitalized or contaminated tissue are removed from a traumatic or infected lesion until the surrounding health tissue is exposed.

“Excisional debridement of the skin or subcutaneous tissue is the surgical removal or cutting away of such tissue, necrosis, or slough; these procedures are classified to the root operation ‘excision.'”

2. How do I code debridement?

If you are coding for debridement of areas other than skin, the procedure is coded to the root operation “excision” (for excisional debridement) or “extraction” (for non-excisional debridement: brushing, irrigating scrubbing, or washing of the devitalized tissue) of the specific body part

Per UI Hospitals & Clinics guidelines, excisional debridement must be documented as “excisional debridement”; use those two words together as a phrase even if all other above conditions are noted.

3. What should I make sure to include?

Make sure your documentation includes all of the following details:

  • The instrument used (scalpel, curette, scissors, Versajet, etc.)
  • Depth (skin, subcutaneous tissue, fascia, tendon, muscle, bone, soft tissue); include thru the site, as coding “to the bone” does not equate to “thru the bone” for accurate documentation.
  • Location of wound (site) laterality and body part

 


References

  • ICD-10-CM/PCS Coding Clinic, Third Quarter ICD-10 2015. Pages: 4-5 Effective with discharges: October 7, 2015
  • ICD-10-CM/PCS Coding Clinic, Third Quarter ICD-10 2015. Pages: 7-8 Effective with discharges: October 7, 2015
  • ICD-10-CM/PCS Coding Clinic, Third Quarter ICD-10 2015. Page: 3 Effective with discharges: October 7, 2015
  • Pinson, R.D., & Tang, C.L. (2017). Reproduced from 2015 CDI Pocket Guide © 2012 HCPro, Ind., 75 Sylvan Street, Danvers, MA 01923. 781/639-1872. www.hcpro.com. Used with permission.
  • Steed, D.L. (2004). Debridement. The American Journal of Surgery, 187 (5,1), S71-74.

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