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Testopel site drainage

David Posted Tue 23rd of June, 2015 12:18:07 PM

We had a patient come in on 3/4/15 for procedure 11980 (zero global day)for his inseration of testopel pellets S0189. Then on 3/11/15 he came back in and the following happened:

CHIEF COMPLAINT
Complaining of drainage from his Testopel site that I just put in last week.
PHYSICAL EXAMINATION
Exam reveals that the stab incision is open, draining serosanguineous fluid. This fluid was cultured with a swab. I then prepped the area and dilated the hole and there is a subcutaneous pocket noted. I could not palpate or feel any of the pellets. I placed a small piece of Nu Gauze to wick it open so it would drain. There is some concern because he has a hip prosthesis on this side, so I am putting him on Augmentin for a while and he is to monitor closely. If he gets fever, pain or purulent drainage, he is to call me, otherwise we will see him back at the end of this week to check the wound.

How would you code this? Should this just be an E/M or can we bill a CPT for the drainage of the implant site? What code would we use? There is no global for 11980 so something is billable.

Thank you

SuperCoder Answered Wed 24th of June, 2015 02:32:59 AM

There is no specific code for this procedure. We cannot take CPT code 10180 (I&D of post operative wound infection) since no incision was made. The wound was already open. The best way to code this procedure is to code appropriate E&M code.

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