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infected open draining wound

Diane Posted Wed 01st of March, 2017 14:59:45 PM
This patient had an infection 2 weeks after a capsulorrhaphy of the metatcarpophalangeal joint of the index finger. THe procedure states Irrigation and debridement of draining wound with removal of sutures from the medial capsule. Then he states nylon sutures were placed through the capsule medially to prevent ulnar drift of the capsule. I am looking at CPT code 11043. But, can I use 26075 Arthrotomy with exploration, drainage or removal of loose or foreign body metacarophalangeal joint? Is the removal of the sutures from the capsule considered foreign body? Also is there another code for suture of the capsule?
SuperCoder Answered Thu 02nd of March, 2017 08:58:35 AM

Here CPT 26075 is not the correct code to select. As per your description arthrotomy is not being performed and here sutures cannot be considered as foreign bodies. In CPT 11043, the physician surgically removes necrotic muscle and/or fascia, including epidermis, dermis, and subcutaneous tissue, if performed. The physician uses a scalpel to excise the affected tissue into the muscle layer. Depending on wound size, closure may be immediate or delayed. The wound may be packed open with gauze and require immediate or delayed reconstruction. CPT 11043 is for the first 20 sq cm or less. But check does your documentation support this code description. On the other hand, CPT code 10180 is for incision and drainage, complex, postoperative wound infection, which is similar to the procedure described by you. This procedure treats an infected postoperative wound. A more complex than usual incision and drainage procedure is necessary to remove the fluid and allow the surgical wound to heal. The physician first removes the surgical sutures or staples and/or makes additional incisions into the skin. The wound is drained of infected fluid. Any necrotic tissue is removed from the surgical site and the wound is irrigated. The wound may be sutured closed or packed open with gauze to allow additional drainage. If closed, the surgical site may have suction or latex drains placed into the wound. If packed open, the wound may be sutured again during a later procedure. In any case suturing will not be billed separately. Check your op-report, match the code description and select the appropriate code according to the performed procedure.

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