Debridement Documentation

Documentation is the key to appropriate code selection. The depth of debridement, manner of debridement, presence of gross contamination and the tissues involved in the debridement or depth of debridement  drive the coding choice.


Debridement procedure notes should include documentaion of the :

• Type of debridement (excisional, non excisional)
• Depth of tissue debrided (skin and subcutaneous, soft tissue, muscle, bone)
• Instrument (s) used to perform the debridement
• Associated diagnosis; if ulcer, document type of ulcer (diabetic, pressure, etc.)
• The nature of the tissue removed ( slough, necrosis, devitalized tissue, non-viable tissue, etc.)
• The appearance and size of the wound