This sample debridement query was provided by Jera Van Damme, BSN, RN, CCDS, senior clinical documentation educator at Essentia Health in Duluth, Minnesota.
This sample has been reviewed and approved by ACDIS’ Forms & Tools Library Committee. The committee recommends that, should you choose to use this sample, you adapt it to your programmatic needs, EHR system requirements, and organizational diagnostic criteria. Before sending this query, the first set of asterisks on the form are to be replaced with the provider’s name, the second set should be replaced with the clinical indicators for that patient, the third set should be replaced with the question at hand, and the fourth set should be replaced with the CDI professional’s name and contact information. Additionally, to allow for accurate coding, those wishing to adapt this query may wish to add the following specifics:
Site of debridement
Type/description (excisional or non-excisional)
Depth (deepest layer debrided—i.e., skin, full or partial thickness, subcutaneous tissue, muscle, or bone)
Tissue removed (devitalized)
Instrument used (scalpel, blade, scissors, etc.)
Appearance and size (character of wound—before and after debridement, include pre/post debridement measurements)
The following is a case scenario featuring ICD-10-CM codes for opioid overdose. This scenario was provided by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, ICD-10-CM/PCS, trainer and procedural coding, compliance, data charge entry, and HIPAA privacy specialist. Webb’s coding specialty is OB/GYN office and hospitalist services, maternal fetal medicine, OB/GYN oncology, urology, and general surgical coding. She can be reached via email at webbservices.lori@gmail.com. You can also find more coding information from her at http://lori-lynnescodingcoachblog.blogspot.com/.
The following coding case scenarios are excerpted from JustCoding’s Guide to Emergency Department Coding by Nena Scott, PhD, MSEd, RHIA, CCS, CCS-P, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, and William L. Malm, ND, RN, CRCR, CMAS, managing director at Health Revenue Integrity Services in Cleveland, Ohio, and Melbourne, Australia.
The following coding case scenarios were reviewed during the HCPro webinar, Strategies for Successful CPT Coding of Lower Extremity Interventional Radiology. This program provides a comprehensive overview of coding and reporting rules for common catheter-based interventions performed in the lower-extremity arteries and veins, such as angioplasty, atherectomy, thrombolysis, thrombectomy, and stent placement.
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This tip sheet originally appeared on on the ACDIS website and was submitted by Nick Stultz, RN, CCDS, CDI specialist at Penn State Health Milton S. Hershey Medical Center.
This sample has been reviewed and approved by ACDIS' Forms & Tools Library Committee. The committee recommends that, should you choose to use this sample, you adapt it to your particular programmatic needs, EHR system requirements, and organizational diagnostic criteria. Additionally, the committee would like to recommend that those adapting this sample for their own use remember that “in the setting of” does not always establish a cause and effect relationship. More specific language may be necessary to adequately link two conditions. For more information on this topic, click here.
