Excisional Debridement

Physician documentation is a key element in obtaining the correct procedure code for excisional debridements that are performed in an inpatient setting. 

Documenting the use of a sharp instrument does not always indicate that an excisional debridement was performed.  The documentation in the medical record for excisional debridement should be described as a definite cutting away of tissue.  The cutting away involves cutting outside or beyond the wound margins, not the minor removal of loose fragments with scissors or scraping away tissue with a sharp instrument.

The following documentation tips can assist in the appropriate code assignment and reporting for excisional debridement:

• Document the level of tissue removed (i.e. skin/subcutaneous tissue, fascia, tendon muscle and or bone.
• Document the surgical removal/excision of tissue (not just “scraping” even with a sharp instrument)
• Document references to the wound infection, necrosis, or the presence of nonviable tissue.
• Document the technique/instrument used when performing the debridement.