Wound Debridement (Bedside)

CPT 97597
Approach Bedside
Add-on / Variant CPTs
  • 97598 — Each additional 20 sq cm (add-on to 97597)
  • 11042 — Debridement, subcutaneous tissue, first 20 sq cm
  • 11043 — Debridement, muscle and/or fascia, first 20 sq cm
Preoperative Diagnosis:

[Chronic wound / surgical wound dehiscence / pressure ulcer / diabetic foot ulcer / traumatic wound] with [necrotic tissue / slough / devitalized tissue / infection]

Postoperative Diagnosis:

Same

Procedure Performed:

Bedside wound debridement, [location]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Nurse/wound care specialist]

Anesthesia:

Local: [X] mL 1% lidocaine [or topical EMLA / wound anesthesia], [IV analgesia: morphine / hydromorphone as needed]

Indications:

The patient is a [age]-year-old [male/female] with a [chronic / acute] [type] wound at [location] measuring [dimensions] with [necrotic tissue / slough / fibrinous exudate / devitalized tissue] requiring debridement to promote wound healing. The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.

Findings:

The wound measured [X × X × X] cm (length × width × depth) at the [location]. [X]% of the wound bed contained [yellow slough / black eschar / necrotic tissue / fibrinous material]. The wound margins were [healthy / indurated / macerated / erythematous]. [Bone / tendon / fascia] was [visible / not visible]. Surrounding skin showed [perilesional erythema / no cellulitis / induration extending X cm from wound edge]. Wound odor was [absent / present (foul/feculent)].

Description of Procedure:

The wound was inspected and photographed. Wound dimensions were recorded: [X × X × X] cm. The wound was prepped with [normal saline irrigation / wound cleanser]. Adequate analgesia was ensured prior to debridement.

Using a [number] 15-blade scalpel, [curved scissors / curette / forceps], all [necrotic tissue / eschar / slough / non-viable tissue] was sharply debrided until a viable wound bed with [punctate bleeding / healthy granulation tissue] was achieved at the wound margins. Tissue planes dissected: [skin / subcutaneous tissue / fascia]. Debridement extended to [describe margin and depth].

Wound dimensions after debridement: [X × X × X] cm. The debrided wound bed demonstrated [granulation tissue / viable subcutaneous tissue / healthy margin bleeding]. No bone or deep structure involvement was identified [or: bone was visualized and probed. Probe-to-bone test was [positive / negative]].

The wound was thoroughly irrigated with [normal saline / dilute Dakin's] under pressure. Hemostasis was achieved with [direct pressure / silver nitrate application / Surgicel]. The wound was dressed with [foam / alginate / silver dressing / negative pressure wound therapy (NPWT) / wet-to-dry gauze].

A wound culture was [sent from tissue biopsy / swab / not obtained] per clinical judgment.

Complications:

None

Specimens:

[Wound tissue biopsy / swab culture sent — aerobic and anaerobic / None]

Estimated Blood Loss:

Minimal

Drains:

None / [NPWT (VAC) applied at -125 mmHg continuous]

Disposition:

The wound was dressed appropriately. Wound care instructions were provided. Follow-up for repeat debridement [was / was not] scheduled. Wound care team / vascular surgery / plastics [were / were not] consulted for ongoing management.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** wound, [location], ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Bedside wound debridement, ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local: *** mL 1% lidocaine / IV analgesia ***

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** wound at *** measuring *** × *** × *** cm with *** requiring debridement. Consent obtained.

PRE-DEBRIDEMENT: *** × *** × *** cm. ***% necrotic/slough. Margins: ***. Surrounding skin: ***. Bone/tendon visible: ***.

PROCEDURE:
Wound photographed and measured. Irrigated with ***. Analgesia ensured. Sharp debridement with 15-blade/scissors/curette. Necrotic tissue removed until viable wound bed with *** achieved. Tissue planes: ***. Irrigated with *** under pressure. Hemostasis with ***.

POST-DEBRIDEMENT: *** × *** × *** cm. Wound bed: granulation/viable tissue. No deep structure involvement.

Dressed with ***. Culture: ***.

COMPLICATIONS: None
DRAINS: ***
DISPOSITION: Wound care instructions provided. Follow-up: ***.

Signed: .ME, .MYDEGREE
.TODAY
Variants

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 (low suspicion for osteomyelitis) / positive (bone palpable, raising concern for osteomyelitis)]. [MRI foot was ordered / podiatry and infectious disease were consulted]. Off-loading was discussed with the patient and orthotic/offloading device was [applied / ordered]. Vascular assessment: pulses were [palpable / doppler-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 [present at X o'clock extending X cm / absent]. 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 consult and wound care team consult 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
  • For CPT billing, document total wound surface area debrided in square centimeters. 97597 covers the first 20 sq cm, and 97598 is added for each additional 20 sq cm. A wound of 45 sq cm = 97597 + 2× 97598. Photographs in the chart support the documented dimensions.
  • Document the depth of tissue debrided. This determines the correct CPT code: 97597/97598 (skin/subcutaneous), 11042/11043 (deeper debridement to fascia/muscle). Billing deeper codes requires documentation that debridement reached those tissue planes.
  • For diabetic foot ulcers, document the probe-to-bone test result. A positive test has approximately 89% PPV for osteomyelitis and mandates further workup. Document vascular status (pulses, ABI if available) since peripheral arterial disease complicates healing and may require vascular surgery input.