Necrotizing Fasciitis Debridement
1100411006wRVU: 12.77 — Necrotizing fasciitis, abdominal wall (without genital involvement)11043wRVU: 2.63 — Debridement, muscle/fascia, per 20 sq cm (extremity/trunk NF)44141wRVU: 29.16 — Colostomy (if diversion required for perianal extension)
Necrotizing soft tissue infection: [Fournier gangrene / necrotizing fasciitis], [perineum / scrotum / abdominal wall / extremity]
Same
Emergent debridement of necrotizing soft tissue infection, [perineum / scrotum / abdominal wall / extremity], with [diverting colostomy / wound VAC]
[Attending name], MD
[Resident name]
General endotracheal. ICU-level monitoring. Vasopressors [in use / on standby]. Blood products available.
Patient presents with [painful / rapidly spreading] erythema, [crepitus / skin necrosis / bullae] of the [perineum / scrotum / abdominal wall / extremity] with systemic sepsis. [CT demonstrates subcutaneous gas / fascial plane gas / fat stranding.] [Diabetes / immunosuppression / obesity present.] LRINEC score [X]. Fournier gangrene severity index [X]. Emergent surgical debridement required; delay increases mortality. Consent [obtained from patient / family / waived; emergent].
Necrotizing infection with [crepitus / subcutaneous gas / fascial plane necrosis] involving [perineum, scrotum, and perineal body / abdominal wall / extremity]. [Gray necrotic fascia / dishwater fluid / loss of normal tissue planes] consistent with necrotizing fasciitis Type [I / II]. Proximal extent of infection: [X]. [Testes viable with intact blood supply / testes involved.] [Rectal sphincter spared / threatened; diversion performed.] All grossly necrotic tissue excised; healthy bleeding tissue at margins confirmed.
The patient was taken emergently to the operating room. The affected area was prepped and draped broadly in sterile fashion.
Wide surgical debridement was performed. Incisions were made through skin and subcutaneous tissue into the area of infection. The fascial plane was entered. Necrotizing infection was encountered: [gray, necrotic fascia / dishwater fluid / loss of fascial integrity]. Debridement was carried in all directions until healthy, bleeding tissue with normal fascial planes was reached at all margins. [Blunt dissection along the fascial plane identified the extent of spread.] All necrotic skin, subcutaneous tissue, and fascia were excised.
[FOURNIER:] The scrotum was [opened and debrided / hemiscrotectomy performed]. The testes were [exposed and found viable; suspended with moist dressings / debrided]. Debridement extended to [perineal body / ischiorectal fossa / abdominal wall / thigh root] as dictated by the extent of infection.
[DIVERTING COLOSTOMY:] Perianal and rectal extension noted; sigmoid loop colostomy created through a [left lower quadrant] trephine incision for fecal diversion.
The wound was irrigated copiously with [X] liters of [normal saline / dilute betadine / chlorhexidine]. Tissue samples sent for gram stain and culture. The wound was packed open with [moist saline gauze / iodoform gauze]. [VAC dressing applied at [X] mmHg to non-perineal wounds.]
Plan for return to OR in [24-48] hours for re-inspection and re-debridement as needed.
Patient tolerated the procedure given the clinical circumstances.
None beyond what was present on presentation
Soft tissue for gram stain, culture, and pathology. [Skin and fascia to permanent pathology.]
[X] mL
[Wound packed open / VAC dressing / colostomy in place]
Patient transferred to surgical ICU intubated. Planned return to OR in 24-48 hours for re-inspection.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Necrotizing soft tissue infection: [Fournier gangrene / necrotizing fasciitis], [perineum / abdominal wall / extremity]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Emergent debridement of necrotizing soft tissue infection, [perineum / scrotum / abdominal wall], [with diverting colostomy]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; ICU monitoring; vasopressors
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with rapidly spreading [perineal / abdominal wall / extremity] necrotizing soft tissue infection. [CT: subcutaneous gas.] [Crepitus / skin necrosis / bullae on exam.] LRINEC ***. FGSI ***. Emergent debridement required. Consent [obtained / waived].
FINDINGS: Necrotizing fasciitis Type [I / II]. [Gray necrotic fascia / dishwater fluid.] Extent: [***]. [Testes viable / involved.] [Rectal sphincter spared / threatened.] All necrotic tissue excised to healthy bleeding margins.
DESCRIPTION OF PROCEDURE:
Emergent OR; broad prep and drape. Wide debridement through skin and subcutaneous tissue to fascial plane; necrotic fascia, skin, and fat excised in all directions to healthy bleeding margins. [Fournier: scrotum opened and debrided; testes viable; suspended.] Extent: [perineal body / ischiorectal fossa / abdominal wall / thigh root]. [Diverting sigmoid loop colostomy via LLQ trephine.] Wound irrigated with *** L saline. Tissue sent for gram stain, culture, pathology. Wound packed open [/ VAC applied]. Return to OR 24-48 h planned.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Soft tissue for gram stain, culture, and pathology
COMPLICATIONS: None beyond presenting condition
DRAINS: Wound packed open [/ VAC / colostomy]
DISPOSITION: Patient to SICU intubated. Re-look 24-48 hours.
Signed: .ME, .MYDEGREE
.TODAYVariants
Re-debridement (return to OR)
Modifier -79 (0-day global). Document extent of new necrosis vs. prior debridement margins, tissue viability at margins, and wound status. Continue until all margins show healthy tissue. Typically requires 2-4 trips to OR.
Extremity necrotizing fasciitis
CPT 11043 per 20 sq cm. Fasciectomy along extremity fascial planes. Document compartment status; perform concurrent fasciotomy if compartment syndrome is present. Amputation may be required for uncontrolled proximal spread.
Type II (Group A Strep / monomicrobial)
More rapid progression, higher mortality than polymicrobial Type I. Document gram stain result if available intraoperatively. Type II often requires even more aggressive debridement margins.
Charting Tips
- Document LRINEC score and FGSI preoperatively (demonstrates clinical severity)
- State infection extent and all anatomic spaces involved at the time of debridement
- Confirm healthy bleeding tissue at ALL margins before closing; the "finger test" (no resistance to blunt dissection) documents fascial plane integrity
- Note testicular viability in Fournier cases; testes have separate blood supply and are often spared
- Document plan for re-look at 24-48 hours explicitly
- Cultures from the deep fascial plane are more accurate than superficial wound swabs
Billing Tips
- Bill 11004 for debridement of necrotizing soft tissue infection of the genitalia, perineum, and abdominal wall (Fournier gangrene, 22.03 wRVU, 0-day global). Bill 11006 for necrotizing fasciitis of the abdominal wall without genital involvement (18.76 wRVU). Bill 11043 for debridement of muscle and/or fascia at other anatomic sites (e.g., extremity, trunk, 5.60 wRVU per 20 sq cm).
- Each return to OR for re-debridement is separately billable with modifier -79 (unrelated procedure, since 0-day global). Document the date, extent of debridement at each session, and the clinical indication for return. Multiple debridements are expected and should each be documented and billed.
- Diverting colostomy performed concurrently for fecal diversion in Fournier gangrene: bill 44141 or 44143 separately. Document the indication (perianal/rectal extension requiring fecal stream diversion).
- Skin grafting for wound closure at a later session: bill STSG codes (15100-15101) at that session. Wound VAC application between debridements is a facility charge; surgeon VAC application in the OR may be billable as wound management.
- The Fournier gangrene severity index (FGSI) should be documented. It correlates with mortality and demonstrates clinical complexity. FGSI >9 is associated with significantly higher mortality.