Sample Coded report (CPT 11043, 11046)
Pre-op Diagnosis: Open wound of right knee, subsequent encounter [S81.001D]
Post-op Diagnosis: Same as Pre-op
Procedure(s):
Right medial knee irrigation and debridement
Right medial knee wound VAC application
Anesthesia: Monitor Anesthesia Care
Estimated Blood Loss: less than 50 mL
Drain: woundvac
Specimens:
ID Type Source Tests Collected by Time
A : right thigh mass Tissue Soft Tissue
Complications: none
Findings: open wound with more necrotic fat proximal to wound
Indications:
This is a 55-year-old female who presents again with an open wound as she continues to perform wet to dry dressings with a slow healing technique with secondary intention which was working well as the patient did not have any further drainage or signs of infection. Unfortunately the patient was having difficulties with the large open wound continuing to do dressing changes and was having a hard mass above the area which could be infectious or could be another area of fat necrosis that is noted every time the patient gets removal of some of her other large areas of fat necrosis. After lengthy discussion the patient did not feel she was capable of continuing with wet to dry dressings and a large wound was making her depressed and causing significant issues. She did not have any help at home so requested we placed a wound VAC on her with irrigation debridement of the area in question proximal to the wound that was hard and painful.
Technique:
The patient was brought back to the operating room and placed in a supine position where she was sterilely prepped and draped. A nonsterile tourniquet was not required for the duration of the case but was present if needed. A time-out was performed with all parties in agreement.
We began by examining the open wound bed which to proximally 3 cm wide and 12 cm long (total length 3×12=36 sq cm). This area was cleaned extensively and there were no signs of infection present. We were able to debride the edges and perform a primary closure of this area however at the proximal edge there was a large area of further fat necrosis about the size of a baseball.
This was carefully excised with sharp dissection using the scalpel as well as electrocautery. Once this was removed there was another large void and in the past the patient has developed large seromas which could become infected in these areas so a black wound VAC sponge was placed in this area and placed to suction with good seal.
At this point we will change her wound VAC every week until we have had complete closure of the wound but would not recommend for any more removal of large fat necrosis deposits unless there exquisitely painful as at this point I did not feel any further areas around the knee with anymore hard masses or any areas of further pain.
Disposition: awakened from anesthesia, extubated and taken to the recovery room in a stable condition, having suffered no apparent untoward event.
Condition: doing well without problems
CPT codes:
11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less
+11046 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
ICD 10 code : S81.001A – Unspecified open wound, right knee, Initial encounter
Wound debridement codes 11042-11047 are reported by the depth of tissue that is removed and by the surface area of the wound. These services may be reported for injuries, infections, wounds, and chronic ulcers. These codes are reported when the intent is not to perform a primary closure, except when debridement is related to a repair that is the primary intent of the service (see Repair Closure guidelines).
The guidelines give direction for reporting single wound debridements that are at different layers in different parts of the wound, and debridement of wounds at the same and different levels. The depth reported for a single wound is the deepest depth of tissue removed. When debridement at the same depth is performed on two or more wounds, the surface areas of the wounds are combined. When the depth of debridement is not the same, the surface areas are not combined.