Health Information Management

Q&A: Coding for debridement of a necrotic muscle not due to an open wound

JustCoding News: Inpatient, May 9, 2012

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

QUESTION: A physician documents in an operative report debridement of a necrotic muscle (not due to an open wound). Must the physician also document how the muscle is removed to report ICD-9-CM procedure code 83.45 (other myectomy)?

Is this considered excisional or nonexcisional debridement? What documentation is required to code the removal of a necrotic portion of a muscle?

ANSWER: Coding Clinic, First Quarter 1999, p. 8, advises reporting code 83.45 for muscle debridement. This guidance doesn’t distinguish between excisional and nonexcisional debridement. The physician would need to document excision of the muscle or excisional debridement. Refer to Coding Clinic, First Quarter 2008, p. 3. If this information is unclear, query the physician.

Editor’s note: Jean Stone, RHIT, CCS, manager of CDI at Lucile Packard Children’s Hospital at Stanford in Palo Alto, Calif., answered the previous question in the May issue of Briefings on Coding Compliance Strategies.

This answer was provided based on limited information that was submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Need expert coding advice? Submit your question to Senior Managing Editor Andrea Kraynak, CPC, at akraynak@hcpro.com, and we’ll do our best to get an answer for you.



Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

    The HIM Director's Guide to ICD-10
  • The HIM Director's Guide to ICD-10

    ICD-10 is the biggest change for the HIM industry since the implementation of DRGs in the 1980s. HIM directors must take...

  • ICD-10 Trainer

    ICD-10 Trainer provides the latest news and updates related to ICD-10 regulations, and tips from HCPro experts and faculty...

  • Coding and You

    Coding and You is written specifically to help non-coders; medical assistants, lab technicians, compliance professionals...

  • Coder Productivity in Today’s Environment

    Insufficient staffing and lack of resources continue to plague HIM departments while they also cope with a move to...

  • Acute and Chronic Renal Failure Coding:

    Our experts address new AKIN criteria, acute vs. chronic kidney disease, and other clinical aspects of renal failure and...

Most Popular