Case: A patient is taken to operating room for I&D (incision and drainage) of abscess. Operative report states: “I&D performed using #16 scalpel, large amount purulent drainage, some necrotic tissue, wound cleaned and irrigated, drain placed.”
Is a query regarding excisional debridement justified?
Answer: A query is warranted in this case. Coding Clinic 1988, 4th Quarter, page 5 states: “Excisional debridement is surgical removal or cutting away of devitalized tissue, necrosis or slough.” In addition, Coding Clinic 2004, 2nd Quarter, page 5 says: “In excisional debridement a scalpel is used to remove devitalized tissue.”
The description of necrotic tissue suggests that it may have been “excised” especially in association with a procedure utilizing a scalpel: good grounds for a query.
Finally, Coding Clinic 2013, First Quarter, page 15 indicates: “It is critical that hospitals work with their providers to ensure that the documentation used to support excisional debridement clearly describes the procedure. Although this may pose some challenges to the coding community, if the documentation is not clear or there is any question about the procedure, the provider should be queried for clarification. To avoid queries, which are frustrating and burdensome to both coders and providers, physicians should be encouraged to provide clear documentation at the point of care.”
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