AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2015 Issue 3; Ask the Editor

Nonexcisional Debridement of Cranial Wound with Removal and Replacement of Hardware

The patient has a history of subdural hematoma evacuation and cranioplasty due to traumatic brain injury. He was readmitted for surgical treatment of subdural empyema, infection, and wound breakdown. At surgery, the previous incision was reopened, the skull hardware was removed, and the bone flap opened. Nonexcisional debridement was performed, removing all infectious material in the cranial wound and subdural and epidural areas. The flap was then re-secured, new plates and screws were placed and the wound closed. How should this procedure be coded?  ...

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