Q&A: Excisional debridement

Q: I have a question about querying for excisional debridement. Our organization uses an operative template containing two sections that have caused some pushback from our surgeons. Those sections are “Procedure performed” and “Operation details.” Our CDI specialists have been sending a query if the procedure performed is not described in the operative details. For example, the procedure performed may say, “excisional debridement subcutaneous tissue,’ but the operative details states ‘removed tissue with scissors.” Our surgeons are telling us that they have documented the procedure in the section “Procedure performed” and that should be enough. Is this an issue for other organizations? If so, what was done to get the surgeons and/or the CDI specialists on the same page?

Response #1: Our CDI department will query if the documentation in the body of the procedure report does not contain all five required elements in order to capture the appropriate excisional debridement. If the noted procedure performed in the operative note lists “excisional debridement subcutaneous tissue,” and the operative details include “removed tissue with scissors” then we require:

• Procedure: “Excisional”
• Instrument Used: “Removed tissue with scissors”
• Depth of debridement: “Subcutaneous tissue”
• Technique Used: “Removed tissue with scissors”
• Nature of tissue (Missing): This is what I see missing in your example. I would query for the appearance and size of the area excised.

Response #2: For excisional debridement I always refer to Dr. La Charite’s article in the ACDIS CDI Blog (“Prevent RAC denials: Improve excisional debridement documentation,” published in January 2011).

To code excisional debridement, all the following must be explicitly stated:

• Type of debridement
• Type of tissue removed
• Instrumentation
• Depth
• Size and etiology of wound
• Type of dressing.

At my last organization, I made a template with the necessary documentation for providers to pull when doing either an operative or bedside debridement.

Response #3: I wanted to share with you our query template (see below) that we have used to help our providers understand what documentation is needed for excisional debridement.
 

Standard Query Template

Query: Debridement

To answer the query, create a new progress note or amend a previous one.

We are seeking further clarification of documentation to reflect the severity of illness of your patient.

Dear Dr./Associates:                                                                             

Per (date) Op Note one or more of the recommended/required elements is missing.

Please clarify in an addendum to the Op Note: (edit options to reflect only missing elements.) ***

__ Type of debridement (excisional or non-excisional)

__ Type of instrument used

__ Dimensions of wound (L x W x D)

__ Type of necrotic/devitalized tissue removed (skin, subcutaneous tissue, fascia, muscle, bone)

__ Location/site with laterality

Please indicate in your reply only if you are unable to determine the diagnosis or if you disagree with the context of the query.

Thank you,

[Name]

***

Best practice is to document your diagnosis/response in the Assessment & Plan and carry through to the Discharge Summary.

This query is not a permanent part of the medical record.

___________________________________________________

Standard Response Template

Response: Debridement

I have reviewed the query and the patient’s medical record, and my response is***

• Type of debridement (excisional or non-excisional)
• Type of instrument used
• Dimensions of wound (L x W x D)
• Type of necrotic/devitalized tissue removed (skin, subcutaneous tissue, fascia, muscle, bone)
• Location/ site with laterality

_____________________________________________________________________________________

Request submitted by: ____________________________

Request date: __________________

Approvals:

CDI:   _________________________

Coding:  ______________________

IT Service Now ticket submitted:  Date ________________________by ________________________________

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and was originally published in the CDI Leadership Insider, a monthly newsletter exclusive to Council members. For the purposes of this article, all Council member answers have been deidentified.