Cracking the Code
Coding Wound Debridement Procedures
Wound debridement is a medical procedure that removes infected, damaged, or dead tissue. The physician’s documentation needs to be descriptive enough to create a very clear picture of the procedure performed. Here are some important tips for reporting wound debridement procedures:
- Technique used: scrubbing, brushing, washing, trimming, or excisional
- Instruments used: scissors, scalpel, brushes, curette, etc.
- Nature of tissue removed: necrosis, devitalized tissue, non-viable tissue, slough, etc. (excisional, selective, or nonselective)
- Appearance and size of wound: fresh bleeding tissue, viable tissue, etc.
- Depth of debridement: skin, fascia, subcutaneous tissue, soft tissue, muscle, or bone
- The depth of debridement is determined by the deepest depth of removed tissue. A patient’s wound may extend to the bone, but the physician may only remove the subcutaneous portion. In this case, the depth of the debridement is to the subcutaneous tissue only.