High-Risk Medical Coding: Debridement Coding, Documentation Challenges, and Insights - AGS Health
To say debridement documentation is challenging is an understatement. It must be descriptive enough to create a clear picture of the procedure performed, a requisite level of detail that is tricky to attain because the procedure title and description within the operative note often do not correlate. Correct debridement documentation will include the following five elements, which provide the level of detail a medical coder needs to assign the appropriate debridement code: Wound, burn, or infection site. Depth of tissue being debrided Instrument used Removal of devitalized or necrotized tissue Mechanism of debridement Without specific and detailed documentation, coders will struggle to accurately determine the type of debridement performed, device used, and/or the tissue depth—all of which can impact reimbursement and compliance and contribute to the already high rate of claims denials related to wound care services. In fact, documentation issues are the culprit behind most denial...