Marie Posted Wed 02nd of October, 2019 12:02:12 PM
Would coding 13160 fit this description or should it be coded to excision with a repair? Background: patient presented to plastic surgery service for chronic non-healing left leg wound with underlying hardware. Dx: leg chronic wound with dystrophic calcification andd tibial cortical changes
1. Excisional debridement of left leg wound and dystrophic calcification
2. Debridement of periimplnat cortical bone
An incision was made over the region of dystrophic calcification and wounds of the left leg. Two of the patient's chronic pretibial wounds were sharply excised down to bone with a scalpel. Tenotomy scissors were used to raise medial and lateral skin flaps over the periosteum. Phlegmonous changes of the tenosynovium of the tibialis anterior were noted and the this tissue was sent for culture. Tissue demonstrating dystrophic calcification was sharply excised. Cortical changes were noted in the anterior tibia, and a rongeur was used to obtain bone culture of this abnormal tissue. A screw head was noted to be in the region of these cortical changes. A pneumatic burr and osteotome were then used to free the screw head from surrounding bone. Unfortunately, the screw was determined to be stripped and unable to be removed. Good, healthy, bleeding bone was noted around the screw head, however.
We copiously wash the wound with 1L NSS. Hemostasis was assured with bovie electrocautery. 2-0 Vicryl was then used to cover the screw head with soft tissue. The wound edges were then reapproximated with 2-0 and 3-0 Nylon suture with retention sutures, vertical mattress sutures, and simple interrupted sutures. The length of the wound lcosure was 16cm. The wounds were then clean, dried, and a soft dressing applied.
SuperCoder Answered Thu 03rd of October, 2019 10:47:53 AM
As per the above mentioned report, the surgeon has perfomed excisional debridement at the level of bone for which the appropriate CPT code is 11045. After debridement surgeon has also performed wound closure (16 cm) with retention sutures for which the appropriate CPT code will be 13121 and 13122 X 2.
So, the CPT codes for above mentioned report are as follows:
13122 X 2
Hope this helps!