Wound Debridement (Bedside)
Bedside sharp wound debridement, [location], [X] sq cm
[Chronic wound / Surgical wound dehiscence / Pressure injury / Diabetic foot ulcer / Traumatic wound] of the [location] with [necrotic tissue / slough / devitalized tissue / infection] requiring debridement to promote wound healing.
[[Verbal / Written] informed consent was obtained after discussion of risks, benefits, and alternatives].
[***, MD/DO]
[None (insensate wound) / Local: [X] mL 1% lidocaine / Topical: EMLA][, with IV [morphine / hydromorphone] analgesia as needed]
Before debridement, the wound measured [X × X × X] cm (length × width × depth). [X]% of the wound bed contained [yellow slough / black eschar / necrotic tissue / fibrinous material]. The wound margins were [healthy / indurated / macerated / erythematous]. The surrounding skin showed [no cellulitis / erythema / induration extending [X] cm from the wound edge]. Wound odor was [absent / foul / feculent]. [No bone, tendon, or fascia was exposed / [Bone / Tendon / Fascia] was exposed]. [The probe-to-bone test was [negative / positive].] After debridement, the wound measured [X × X × X] cm, and the wound bed demonstrated [healthy granulation tissue / viable subcutaneous tissue / punctate bleeding].
[A time-out was completed confirming the patient, procedure, and site.] The wound was inspected, measured, and photographed. The wound was cleansed with [normal saline irrigation / wound cleanser]. Adequate analgesia was confirmed before debridement.
Using a [15-blade scalpel / curved scissors / curette] and forceps, all [necrotic tissue / eschar / slough / nonviable tissue] was sharply debrided until a viable wound bed with [punctate bleeding / healthy granulation tissue] was reached at the wound margins. Debridement was carried to the level of [epidermis and dermis / subcutaneous tissue / fascia / muscle], with a total debrided area of [X] sq cm.
The wound was irrigated with [normal saline / dilute Dakin's solution] under pressure. Hemostasis was achieved with [direct pressure / silver nitrate / Surgicel]. The wound was dressed with [a foam dressing / an alginate dressing / a silver dressing / wet-to-dry gauze].
Minimal
[Debrided tissue sent for aerobic and anaerobic culture / Wound swab sent for culture / None]
None
Wound care instructions were provided. Repeat debridement [is / is not] planned. [[The wound care team / Vascular surgery / Plastic surgery] was consulted for ongoing management.]
Epic SmartPhrase Version
PROCEDURE: Bedside sharp wound debridement, ***, *** sq cm
INDICATION: *** of the *** with *** requiring debridement to promote wound healing.
CONSENT: [Verbal / Written] consent obtained after discussion of risks, benefits, and alternatives.
PERFORMED BY: ***, MD/DO
ANESTHESIA: [Local: *** mL 1% lidocaine / Topical: EMLA], IV analgesia ***
FINDINGS: Pre-debridement *** × *** × *** cm. ***% slough/necrotic. Margins: ***. Surrounding skin: ***. Odor: ***. Exposed bone/tendon/fascia: ***. Probe-to-bone: ***. Post-debridement *** × *** × *** cm, wound bed ***.
PROCEDURE DETAILS:
[Time-out completed.] Wound inspected, measured, and photographed. Cleansed with ***. Analgesia confirmed. Sharp debridement with [15-blade / scissors / curette] and forceps of *** until viable wound bed with *** reached. Debrided to the level of ***, total area *** sq cm. Irrigated with *** under pressure. Hemostasis with ***. Dressed with ***.
EBL: Minimal
SPECIMENS: ***
COMPLICATIONS: None
POST-PROCEDURE PLAN: Wound care instructions provided. Repeat debridement: ***. Consults: ***.
Signed: .ME, .MYDEGREE
.TODAYVariants
Diabetic Foot Ulcer
A diabetic foot ulcer at the [plantar surface / toe / heel] of the [right / left] foot was debrided. Callus and hyperkeratotic tissue were removed from the wound margins. The probe-to-bone test was [negative / positive, with bone palpable]. [An MRI of the foot was ordered.] [Podiatry and infectious disease were consulted.] Offloading was discussed with the patient, and an offloading device was [applied / ordered]. Pedal pulses were [palpable / Dopplerable only / absent]. Vascular surgery [was / was not] consulted.
Pressure Injury (Stage 3/4)
A stage [3 / 4] pressure injury at the [sacrum / coccyx / ischium / heel] measuring [X × X × X] cm was debrided. [Tunneling / Undermining] was [absent / present at [X] o'clock, extending [X] cm]. The deepest tissues visualized were [subcutaneous fat / fascia / muscle]. No bone was visible or palpable. A tissue culture was sent. NPWT [was / was not] applied. Nutrition and wound care team consults were placed.
Negative Pressure Wound Therapy (NPWT / VAC) Application
Following debridement, negative pressure wound therapy was applied. The wound was sized and the foam dressing cut to fit. The foam was placed in the wound cavity without overpacking. An occlusive drape was applied creating an airtight seal. The NPWT device was connected and set to -125 mmHg continuous pressure. Seal was confirmed by the device achieving target pressure. The NPWT dressing is to be changed every [48-72 hours].
Charting Tips
- Document total wound surface area debrided in square centimeters, because each 20 sq cm increment is billed as a unit. Photographs in the chart support the documented dimensions.
- Document the depth of tissue debrided. Selective debridement applies to skin-level debridement, and surgical debridement applies when debridement reaches subcutaneous fat or deeper. Document the deepest tissue plane reached to support the selected code family.
- For diabetic foot ulcers, document the probe-to-bone test result. A positive test has approximately 89% PPV for osteomyelitis and mandates further workup. A negative test indicates low suspicion for osteomyelitis. Document vascular status (pulses, ABI if available) since peripheral arterial disease complicates healing and may require vascular surgery input.
Documentation & Reimbursement Considerations
- Primary service: Report Wound Debridement (Bedside) as the primary service when it is the definitive operation performed.
- Selective debridement of devitalized tissue at the skin level is billed as a base service for the first 20 sq cm plus an add-on unit for each additional 20 sq cm or part thereof, so a 45 sq cm wound is the base service plus two add-on units.
- Selective debridement and surgical debridement are mutually exclusive code families for the same wound in the same session. Choose the family by the deepest tissue plane debrided: selective debridement for skin level, and surgical debridement for subcutaneous fat or for muscle and fascia, each with a first-20 sq cm service and an add-on for each additional 20 sq cm. Document total debrided area in sq cm and deepest tissue plane reached.
- Selective debridement requires a selective (mechanical) technique documented in the note and may be performed by a physician or qualified practitioner, while surgical debridement requires physician performance. Enzymatic (collagenase) and autolytic debridement are not reported with the selective debridement services.
- For inpatient hospital debridement, wound care by nursing staff is typically bundled into facility charges. Physician billing is appropriate when the physician personally performs the debridement and documents it separately.