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debridement help please

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can someone help explain to me how to code this thanks

Procedure:
Sharp excisional debridement of muscle 13 x 4 cm ?11043 11046 x2
Primary closure of fasciotomy sites 13 x 4 cm and 10 x 2 cm ?
Findings:
Nonviable muscle on the lateral aspect of the fasciotomy site and this was sharply debrided down to bleeding healthy muscle.

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Procedure Details:
The patient was operating room placed in supine position. Gen. anesthesia was induced. The right lower extremity was prepped and draped in the usual sterile fashion. A timeout was performed verifying correct patient and procedure. The previous fasciotomy sites were explored and on the lateral incision the muscle was noted to be dark and dusky. This was sharply excised with some bumps his back to healthy bleeding muscle. Total muscle debrided measured approximately 13 x 4 cm. The medial fasciotomy site was explored and the muscle viable. Both wounds irrigated copiously. Hemostasis was achieved. The wounds were then closed with interrupted deep dermal absorbable suture and the skin was closed with staples and interrupted nylon sutures. Skin edges came together without any tension. Incisions were then dressed. At this point the procedure was ended.
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Instrument, sponge, and needle counts were correct prior to closure and at the conclusion of the case. The patient tolerated the procedure well and was transferred to the PACU in stable condition.
 
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Hello CTVS2019,

I would query the provider for the depth and measurement of the medial fasciotomy exploration and closure. Also, where are you getting the 10X2 measurement?
Here is what I am thinking with the info provided:

*Lateral fasciotomy site: Debridement to the muscle 13X4= 52 sq cm so CPT 11043 & CPT 11046; the closure is included in the debridement code.
*Medial fasciotomy site: Exploration of fasciotomy then closure including deep dermal layer and skin, no measurement given (currently) so CPT 12031-51.

Please see below for the code description of 11043 to see that closure is included:

The physician surgically removes necrotic muscle and/or fascia, including epidermis, dermis, and subcutaneous tissue, if performed. The physician uses the appropriate surgical instrument (i.e., scalpel) to excise the affected tissue into the muscle layer. The dissection is continued until viable, bleeding tissue is encountered. Depending on wound size, closure may be immediate or delayed. The wound may be packed open with gauze and require immediate or delayed reconstruction.

Hope this helps~

M.Hannus, CPC, CPMA, CRC
 
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debridement

the doctor used 10x2 measurement in the procedure title but i didn't see it in the note so I wasn't sure. that was his actual note.
Is there specifics that the doctor should be documenting to be able to select the correct cpt code?
I will ask about the depth.
 
Messages
173
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0
the doctor used 10x2 measurement in the procedure title but i didn't see it in the note so I wasn't sure. that was his actual note.
Is there specifics that the doctor should be documenting to be able to select the correct cpt code?
I will ask about the depth.
Ok~ yes I definitely would be questioning the doctor :)
 
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