AHA Coding Clinic® for ICD-9 - 2008 Issue 3; Ask the Editor

Incision and Drainage with Excisional Debridement

The patient is a 57-year-old man with multiple medical problems. He is morbidly obese and has severe venostasis disease. The patient had a history of trauma to his left lower extremity that resulted in a subcutaneous hematoma. The patient now presents with an area of necrosis of the skin with overlying cellulitis. There was a large area of necrotic skin with a large area of protuberance underneath it, which was documented by physical exam and confirmed with CT scan. The patient was taken to the operative suite. An incision was made along the border of the area of skin necrosis. Suction was placed into the compartment and the subcutaneous tissue and approximately a liter of bloody purulence was removed. The surgeon then proceeded to unroof the abscess cavity by removing/excising the necrotic skin. The area of necrosis was about 18 x 12 inches. The cavity was then packed and wrapped with Ace bandages. We believe that it is appropriate to assign both 86.04 and 86.22 since the abscess was drained and the cavity was unroofed and excised. How should this surgery be coded? ...

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