Tammy Posted Thu 10th of January, 2019 09:52:50 AM
PT IS POST OP FROM AN OPEN RADICAL NEPHRECTOMY...TODAY IS HAVING A WOUND EXPLORATION, WASHOUT AND COMPLEX WOUND CLOSURE WITH VENTRAL ONLAY MESH (5CM)....WOUND OPENED SUPERFICIALLY AND PT NOTED EXPOSURE OF BOWEL CONTENTS AND ELECTED FOR CLOSURE. WHAT CPT CODES AND ICD-10 CODES SHOULD I USE? I WILL APPEND A MODIFIER: 78 TO IT. THANKS...
SuperCoder Answered Fri 11th of January, 2019 08:24:55 AM
Thank You for your Question.
As per the above documentation CPT code 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated) and ICD 10 CM code T81.32XA (Disruption of internal operation (surgical) wound, not elsewhere classified, initial encounter) would be appropriate.
Append modifier 78 if this procedure was unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period.
Hope this helps!