Wiki Debridement

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lsolway

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After a lengthy research, I'm still not finding an appropriate answer. On the ED report, Clinical Impression: Debridement of erosive facial neoplasm (cheek). Course of Care: Suctioning of the maggots was preformed many times. At the termination of the procedure, no maggots were able to be found.
Notes: large abscess/ ulcer to orbital and cheek, xeroform dressing and opifoam to cover wound.
Considered 11042-11043, no anesthesia mentioned, only Norco given. Or included in ED Level? Thanks
 
Is this the complete note? 11042-11043 would not be supported here since there is no documentation of removal of tissue or the depth or size of the debridement. I'd suggest 97602 is more likely correct instead since that includes larval therapy (though it's not clear if these are maggots placed therapeutically or due to an infestation), however the note still doesn't document removal of tissue.
 
thomas7331 said:
Is this the complete note? 11042-11043 would not be supported here since there is no documentation of removal of tissue or the depth or size of the debridement. I'd suggest 97602 is more likely correct instead since that includes larval therapy (though it's not clear if these are maggots placed therapeutically or due to an infestation), however the note still doesn't document removal of tissue.
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Yes, that's the complete note for the procedure done. No depth or size mentioned other than "erosive wound left face, entire cheek absent". It was an infestation of maggots, not therapeutic. The only "debridement" mentioned is in the Clinical Impression (above). Would you recommend I query the physician?
 
lsolway said:
Yes, that's the complete note for the procedure done. No depth or size mentioned other than "erosive wound left face, entire cheek absent". It was an infestation of maggots, not therapeutic. The only "debridement" mentioned is in the Clinical Impression (above). Would you recommend I query the physician?
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You could do that, depending on your query process and ease of access to the providers. I think I would probably just consider it inclusive to the E&M service. Removal of a foreign body from skin/subcutaneous tissue without incision, which is what this sounds like, would generally not be coded separately anyway.
 
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