Wiki Debridement -help

codedog

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Not sure if I should code 11045, 11046, or 97597, 97598, any ideas?
Patient had a right trochanteric decubitus ulcer with a wound vac placement (less than 100 cm area ) debrided to healhthy tissue. The greater trochanter now exposed in wound.

Operative report.

The right hip was then prepped with betadine and draped in the standard fashion. Devitalized tissue was debrided sharply to the level of healthy appearing tissue. Unfortunately, removal of the non-viable tissue exposed the greater trochanter. Hemostasis was achieved. A white vac sponge was used on the deepest tissue, followed by the black sponge and transpent dressing. A Vac was connected to suction and functioned normally.
 
not the greatest documentation. Cant do size since not mentioned, so the smallest and they really should mention the tissues debrided but from the note it would be 11043 and also I can't tell if its DME Vac or not so either 97605 or 97607 and depending on if size is mentioned 97606 or 97608. Hope that helps.
 
Below is a list of documentation requirements I received from Medicare, I have my Dr's follow these guidelines for all debridement procedures.Hope this helps in the future. 11042-11047.DOCUMENTATION REQUIREMENTS:1. TOOL USED FOR DEBRIDEMENT (CURETTE, SCAPEL, OTHERINSTRUMENTS)2. FREQUENCY OF SURGICAL DEBRIDEMENT.3. MEASUREMENT OF TOTAL DEVITALIZED TISSUE (WOULD SURFACE)BEFORE AND AFTER SURGICAL DEBRIDEMENT.4. AREA AND DEPTH OF DEVITALIZED TISSUE ACTUALLY REMOVED FROMWOUND (NOT JUST DEPTH OF WOUND).5. BLOOD LOSS AND DESCRIPTION OF TISSUE REMOVED.6. PROGRESS NOTES OR PROCEDURE NOTES WITH A DETAILEDDESCRIPTION OF THE PROCEDURE.7. EVIDENCE OF THE PROGRESS OF THE WOUND'S RESPONSE TOTREATMENT. THIS DOCUMENTATION MUST INCLUDE AT A MINIMUM: A. CURRENT WOUND VOLUME CSURFACE DIMENSIONS AND DEPTH B. PRESENCE (AND EXTENT OF) OR ABSENCE OF OBVIOUS SIGNS OF INFECTION C. PRESENCE (AND EXTENT OF) OR ABSENCE OF NECROTIC, DEVITALIZED DR NON-VIABLE TISSUE D. OTHER MATERIAL IN THE WOUND THAT IS EXPECTED TO INHIBIT HEALING OR PROMOTE ADJACENT TISSUE BREAKDOWN
 
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