Documentation Tip of the Week: Excisional Debridement

Posted on Wed, Apr 22, 2015
Documentation Tip of the Week: Excisional Debridement

Documentation tips for clinicians

Excisional Debridement Physicians/providers must now document “excisional debridement of bone, fascia or muscle,” otherwise the procedure will be coded as nonexcisional. Terms such as “sharp debridement” or statement of use of a scalpel alone are not considered sufficient for code assignment of excisional debridement.

The following information must also be documented by the provider:

  • Description of the area debrided
  • The instrument used (scalpel, scissors, forceps, etc.)
  • The depth of the debridement (up to and including skin, muscle, tendon, bone, etc.)  
  • Documentation of removal or cutting away of devitalized tissue, necrosis or slough

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 physician reimbursement and/or denials.

Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.

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