Camille Posted Tue 22nd of October, 2019 12:50:03 PM
Indication: Pt underwent surgical repair of a chronic Achilles Tendon rupture. Unfortunately, he had a small site of the wound that failed to close completely. Procedure Description: Attention was directed to the posterior aspect of the left leg. We kept him in a supine position to keep any stress on him as minimal as possible. We bent his knee and found what was a very small punctate lesion where he had his drainage. We ellipsed this entire area out in a 3 to 1 method. The area was undermined. The tissue itself had a small aperture in the center that we could see from the inferior aspect. his was all sent to Pathology for microscopic evaluation. We then used a combination of undermining to allow us to close this. There was a fair amount of scar tissue that was removed as well. We did find 2 strands of the suture material that was used to repair the tendon. These were placed on stretch and excised sharply. We then examined for any deep abnormalities, non of which was found. There did not appear to be any deep pockets of pus or other abnormalities. There were no cyst-like lesions. The entire site was then undermined so that the edges would come together without tension. The site was flushed with large amounts of sterile saline after which it was then closed with meticulous care utilizing some 3-0 Monocryl and some 3-0 nylon...Is this coding correct: 13160/T81.31XA, 10121/M60.262? Thank you very much!
SuperCoder Answered Wed 23rd of October, 2019 05:18:35 AM
In the procedure code 13160, the physician debrides, or scrapes away, granulating tissue or excises dehisced tissue, tissue that has separated, from a wound that was previously left open because of contamination or other concerns. The wound requires extensive debridement, or the procedure is complicated by the size or location of the wound. It may require a complex closure due to loss of tissue or skin to cover the wound. The provider closes the wound and applies antibiotics and a dressing.
On the other hand, removing 2 strands of the suture material might not considered as the complicated, so CPT 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) may be used for simple complexity instead of 10121.
It is suggested to append the modifier 52 (Reduced Services) with the CPT 10120 because there is no separate incision required for foreign body removal. Diagnosis codes T81.31XA and M60.262 are appropriate for Disruption of external surgical wound and Foreign body.
Hope this helps!
Camille Posted Wed 23rd of October, 2019 16:05:05 PM
Thank you! Will you please clarify; do you agree that one could also code the 13160 (as well as the 10120-52)?
SuperCoder Answered Thu 24th of October, 2019 06:30:13 AM
Hope you are keeping well.
In CPT code 13160, the physician debrides, or scrapes away, granulating tissue or excises dehisced tissue, so removing two strands of the suture material from the dehisced tissue might not be paid separately. However, there is no NCCI edits between both the procedure codes, these can be billed together. Although, in your scenario, clinical representation of removal of foreign body is not so strong, so there is less chance of procedure 10120 to be get paid.
Still, if your complete documentation supports the removal of foreign body, then you can bill it.
Hope this helps!
Camille Posted Thu 24th of October, 2019 14:34:40 PM
Yes, you've been a great help! Thank you kindly!
SuperCoder Answered Fri 25th of October, 2019 03:39:09 AM
We are happy to help!
Wish you best reimbursement.