Kathy Posted Mon 28th of September, 2015 13:36:57 PM
My doc would like to bill CPT 10121 (Incision and Removal of FB) for a suture removal of a suture that did not dissolve as it was supposed to and created a sinus cavity. I'm unsure that qualifies as a FB and therefor wonder if I should use CPT 15850 for suture removal under anesthesia. Please advise. Thank you!
Indication: ...She underwent rt hemicolectomy through an upper midline incision. The incision was left open and allowed to heal in by secondary intention using a wound VAC. The incision has actually healed very well, but she has one sinus at the superior aspect of the incision. A month and a half ago the suture was visible at the bottom of this incision, but I felt it was too early to remove the suture as I was concerned that the fascia would dehisce. I feel the fascia has healed sufficiently that the suture can now be moved to allow the wound to heal.
Findings: On exploration of the wound she was found to have the PDS suture at the base of the sinus tract, the superior aspect of her wound and 4 pieces of suture were removed. The wound was clean with no evidence of infection. The inferior aspect of the wound was almost essentially clean.
Description: ...The wound was extended superiorly to allow access to the deeper tissue. The wound was explored and 4 separate pieces of suture were found and removed. No further suture knots were identified. The wound was then packed with half inch iodoform gauze and sterile dressing was applied. She will be evaluate by wound nurse in recovery room for placement of a wound VAC.
SuperCoder Answered Tue 29th of September, 2015 01:57:50 AM
AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail email@example.com for more information.