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According to Coding Clinic, in order to code an excisional debridement, providers must explicitly document that this was done otherwise, this can’t be coded hence, negatively affecting the DRG for the case. For this assignment , let’s assume the provider has not explicitly stated whether or not an excisional debridement was performed. Following the rules mentioned in the article below on compliant queries, DO a compliant query for an excisional debridement. USE THE FOLLOWING OPERATIVE REPORT FOR THIS ASSIGNMENT: Query Assignment: Based on coding clinic and OIG requirements, explicit documentation for “excisional debridement” is necessary in order to capture EXCISION PCS codes for these procedures. Use the noncompliant documentation below to query your fictional doctor. Research how to create a non-leading query on this topic. Don’t forget to include options for your doctor including the option for free text or “other”. OPERATIVE REPORT: PREOPERATIVE DIAGNOSIS: Open wound left lower extremity status post fasciotomies of the left lower extremity for compartment syndrome status post external fixator for left tibial plateau fracture. POSTOPERATIVE DIAGNOSIS: Open wound left lower extremity status post fasciotomies of the left lower extremity for compartment syndrome status post external fixator for left tibial plateau fracture. PROCEDURE PERFORMED: Irrigation and debridement of the left lower extremity down to muscle of the medial and lateral wounds, both greater than 10 cm each. ANESTHESIA TYPE: General. ESTIMATED BLOOD LOSS: Less than 10 mL COMPLICATIONS: None. INDICATIONS FOR SURGERY: The patient is a 59-year-old male with the above diagnosis. The patient had initial application of external fixator and fasciotomies performed by my partner on November 23rd. The patient had open wounds, initially had application of a wound VAC with the intent to bring him back to the operating room for repeat I and D, possible ORIF, possible wound closure. Preoperatively, the patient’s leg had too much soft tissue swelling. He did not have a positive wrinkle sign, so the soft tissues were too swollen to proceed with definitive fixation, so the decision for maintaining the fixator and just doing irrigation and debridement along with possible wound closure was made at that time. Risks and benefits were explained to the patient. He made an informed decision to proceed with the above procedure. PROCEDURE: The patient was seen preoperatively. The left lower extremity was marked. He was brought in the operating room, placed on the operating table, given a general anesthetic. The left lower extremity was then thoroughly prepped and draped in standard orthopedic fashion. Once that was done, universal protocol of a time-out was taken to confirm that the left lower extremity was the correct operative site. Once that was done, 3 liters of lactated Ringer’s laced with bacitracin was used for both medial and lateral wounds. Any nonviable or necrotic subcutaneous tissue was debrided down from both wounds. There was not an excessive amount of bleeding, and the wounds were closed with interrupted subcutaneous 2-0 Vicryl for the subcutaneous layer and a running 4-0 V-Loc for the skin. Wounds were then dressed with Steri-Strips, Xeroform, 4 × 4s and Ace wrap. Xeroform was also placed around the pin sites for the external fixator which was also prepped out from the procedure. The patient was also noted to have some fracture blisters and several abrasions to the skin. Once the leg was dressed, the patient was extubated and transferred to postanesthesia recovery unit in stable condition. All sponge and sharp counts were correct. The patient received preoperative antibiotics and will receive postoperative antibiotics. He is nonweightbearing. He will be placed back on his anticoagulant treatment, most likely Lovenox, for DVT prophylaxis and he will be discharged at the discretion of Trauma Service to follow up in the office for reevaluation and determine when definitive fixation will be performed. AHIMA Article on Compliant Queries (Links to an external site.) Coding Clinic Advice: Excisional and nonexcisional debridement ICD-10-CM/PCS Coding Clinic, Third Quarter ICD-10 : 3 Effective with discharges: Debridement of the skin and subcutaneous tissue is a procedure by which foreign material and devitalized or contaminated tissue are removed from a traumatic or infected lesion until the surrounding healthy tissue is exposed. Excisional debridement of the skin or subcutaneous tissue is the surgical removal or cutting away of such tissue, necrosis, or slough and is classified to the root operation “Excision.” Use of a sharp instrument does not always indicate that an excisional debridement was performed. Minor removal of loose fragments with scissors or using a sharp instrument to scrape away tissue is not an excisional debridement. Excisional debridement involves the use of a scalpel to remove devitalized tissue. Documentation of excisional debridement should be specific regarding the type of debridement. If the documentation is not clear or if there is any question about the procedure, the provider should be queried for clarification. A code is assigned for excisional debridement when the provider documents “excisional debridement,” and/or the documentation meets the root operation definition of “Excision” (cutting out or off, without replacement, a portion of a body part). Nonexcisional debridement of the skin is the nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis, slough, or foreign material. Most nonexcisional debridement procedures are classified to the root operation “Extraction” (pulling or stripping out or off all or a portion of a body part by the use of force).

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