Health Information Management

Tip: Look for appropriate documentation for selective wound debridement

APCs Insider, July 27, 2012

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The removal of devitalized tissue is called selective debridement or active wound management. Coders should only report these codes once per visit, ­regardless of how many wounds are debrided. These codes are only used when a provider removes nonviable tissue, and coders should not see documentation of bleeding (which indicates living tissue).

Documentation for selective debridement must include the following elements:
  • Location and characteristic of lesion
  • Depth (should be minimal)
  • Type of tissue removed (nonviable)
  • Instrument used (can be sharp)
  • Patient's tolerance
  • Dressings applied and treatment plan
The tip is adapted from “Differentiate between types of wound debridement” in the June Briefings on APCs.



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