Wiki Excisional debridement abdominal skin, sub-q fat, fascia and fasciotomy


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I am STUMPED. Can anyone give me a place to start on this one? I feel I need to query the surgeon, but not even sure what questions to ask.....

The op note reads as follows: Procedure: Excisional debridement abdominal skin, sub-q fat, fascia and fasciotomy. Diagnosis: Necrotizing fasciitis

Intraoperative findings: Patient had dishwater colored fluid and infected sub-q fat that was devitalized in the right lower abdominal wall extending over to the right flank. An extremely large incision was made in order to clean out this area and the wound was packed and she was sent to the ICU in critical condition.

Patient was taken emergently to the OR as CT preoperatively showed a large amount of air and sub-q infection. A transverse incision was made on the patient's right lower abdomen and the sub-q tissue was divided with cautery. Large amount of skin had to be excised along with sub-q fat and fascia. The fascia was opened up laterally and the underlying muscle appeared to be viable. There was thick purulent material in the area of the right lower quadrant where she had a previous colostomy and this was cleansed and devitalized fat was cut out and the wound was then irrigated with pulsavac and the wound was packed with moist kerlix gauzes.

Thank you!!!
The codes would likely be 11043 & 11046 for debridement to the level of the muscle and fascia, but you're correct that you'd need to query the provider because they haven't documented any measurements of the wound area debrided which you need in order to be able to correctly code this. If this is a Medicare patient, you might also want to check to see if your local contractor has any other specific documentation requirements for debridement services - some of the LCDs require specific information in the documentation such as the type of instruments used and the indications for the services.