Excisional Debridement coding requirements, tips

Query on debridement? Avoid excisional assumptions

Clinical Documentation Specialists (CDS) frequently query for specification of debridement. To accurately code a debridement, three pieces of information must be documented by the provider/surgeon in the patient’s chart: 1) excisional vs. non-excisional; 2) deepest level of tissue removed; 3) location of debridement.

• Excisional: surgical removal or cutting away of devitalized tissue, necrosis, or slough using a scalpel or curette.

• Non-excisional: Cleaning, brushing, scrubbing, washing, irrigating of a wound; chemical or enzymatic treatment; or minor trimming/scraping to remove fragments of dead tissue.

• Deepest layer of tissue removed: Specify skin, subcutaneous, fascia, muscle, tendon, or bone.

For clarity: In medical coding, excisional means: “cutting out or off, without replacement, a portion of a body part.”

Coders may not assume that debridement of bone, fascia or muscle is excisional. Nor may they assume that sharp debridement is excisional. The exact wording of ‘excisional debridement’ with the supporting documentation must be present. Failure to document appropriately may result in problems with billing denials.

Documentation tips:

• Terms such as “sharp debridement” or stating use of a scalpel are not considered sufficient for code assignment of excisional debridement.

• Sharply debrided indicates than an excision was performed, but the debridement must be further specified as excisional or non-excisional.

• The provider must document: Excisional debridement of ________ (skin, fascia, muscle, tendon, or bone). If this information is omitted, the procedure will be coded as non-excisional.