June 8, 2017

Question:
My doctor’s operative note said he did a wound debridement of an ankle non-pressure ulcer (the patient is diabetic) “down to the muscle”.  He wants to use 11043 (debridement including muscle) and I say it is 11042 (debridement of subcutaneous tissue).  What do you think?

Answer:
Technically, the documentation should state “down to and including the muscle” to use 11043 because this code includes debridement of muscle.  Saying “down to” the muscle does not specifically state muscle was actually debrided.  So, we recommend 11042.

*This response is based on the best information available as of 06/08/17.