Did You Know? Debridement and Pressure Ulcers
The Clinical Documentation Excellence Program hopes this information will be valuable to you as you document, assure the accuracy of severity of illness and risk of mortality, and substantiate the correct DRG assignment for reimbursement.
Incision and Debridement
Per coding guidelines, an excisional debridement is defined as the surgical removal or cutting away of devitalized tissue, necrosis, or slough as opposed to a mechanical (brushing, scrubbing, or washing) debridement. Any debridement that is not specified as excisional is by default coded as non-excisional.
Incision and debridement is often documented and referred to as incision and drainage, not incision and debridement.
Please specify in your documentation these key indicators:
- Technique – scrubbing, brushing, trimming, or excisional
- Instruments – scissors, scalpel, curette, brushes, pulse lavage, etc.
- Nature of tissue removed – slough, necrosis, devitalized tissue, non-viable tissue, etc.
- Appearance and size of wound – fresh bleeding tissue, viable tissue, etc.
- Depth of debridement – skin, fascia, SQ tissue, soft tissue, muscle, bone
Without documentation of all of the above, the procedure may be coded as non-excisional as it was not clear whether an excisional technique was performed.
Pressure Ulcers
In order for proper coding of pressure ulcers, the physician must address the ulcer in his/her documentation, dictation, or by signing the sticker in the WOCN areas within the Physician Progress Notes (Saint Luke’s Hospital – Plaza location only). Without physician acknowledgement of the pressure ulcer, it cannot be coded.
For questions, please contact the Clinical Documentation specialist at your facility.