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Delayed Closure and Sesamoidectomy

My provider took a patient to the OR for I & D of diabetic foot ulcer [10160] and also took a bone bx [20240], leaving the wound open.
6 days later he returned to the OR for delayed wound closure… the surgeon freshened the wound edges then removed the sesamoid bone thru the initial incision.

My question:
Can I capture the delayed closure even though he used the same incision as his approach for the sesamoidectomy [28315-58]?

I say no…my provider and a co-worker say yes. Any thoughts?
Thanks in advance…

Medical Billing and Coding Forum

CPT 27884 and 11044 – further excision of bone prior to secondary wound closure

Good Afternoon:

Patient had a BKA and returned to the operating room for stump site irrigation, debridement and secondary closure. The physician dictated the following:

"…Then, debridement of the soft tissues were carried out along with the skin. The fibula was also excised about a centimeter proximal to the tibial cut and tibial cut was beveled.

I’d like to use 27884 and 11044 but can’t because of column 2/1 misuse edits.

Any suggestions on how to code this so the physician is paid for the secondary closure, irrigation and, specifically, the further excision of bone…

Thank You – Melissa

Medical Billing and Coding Forum

Left ureteral implantation w/ closure of vesicostomy

Please help with this one. I work coding denials for multispecialty practice and need some help with urology. This is a pediatric patient. This procedure was for closure of a vesicostomy and left ureteral implantation. The initial coder coded this procedure with 50780 and 51880-51 and the 51880-51 was denied as incidental. 51880 is a "separate procedure", so I know it either gets billed alone or with a 59 mod if reported with an unrelated procedure. My question is basically is the 50780 truly an unrelated procedure from the 51880 or should the 50780 encompass the whole procedure. There is no CCI edit between the two. Here’s the note:

PREOPERATIVE DIAGNOSIS:
1. Neurogenic bladder with vesicostomy.
2. Left grade 4 vesicoureteral reflux.

POSTOPERATIVE DIAGNOSIS:
1. Neurogenic bladder with vesicostomy.
2. Left grade 4 vesicoureteral reflux.

PROCEDURE:
1. Closure of vesicostomy
2. Left ureteral reimplantation.

INDICATIONS:
Patient is a 13-year-old boy with low level myelomeningocele with resulting bowel and bladder dysfunction. He has been managed with vesicostomy due to his unwillingness to perform intermittent catheterization. He is now performing intermittent cath and would like closure of the vesicostomy. There is also grade 4 left reflux which persists despite previous Deflux injection.

FINDINGS:
Vesicostomy with evidence of chronic bladder inflammation. Deflux injection sites noted around left orifice with significant fibrosis.

DESCRIPTION OF PROCEDURE:
After adequate general anesthesia was obtained, the patient was placed in a supine position and the external genitalia and lower abdomen were prepped and draped in usual sterile fashion. A 12-French Foley catheter was inserted in the vesicostomy site and the balloon inflated. A transverse incision was then made encompassing the vesicostomy site and carried down to the rectus fascia. This was opened transversely and elevated in the fashion of a Pfannenstiel incision. The vesicostomy site was secured with 2 sutures of 3-0 silk and dissected free from the rectus muscles. The bladder was then opened in the midline. The mucosa was noted to be mildly inflamed throughout. The Bookwalter retractor was then brought onto the field and placed in such a manner as to allow adequate visualization of the bladder interior. Despite this, however, there was exceptional difficulty seeing the area of the trigone due to superior location of the vesicostomy incision. For this reason the rectus fascia was then divided in the midline inferiorly to allow further separation of the muscle and better visualization of the base of the bladder. The left ureteral orifice was identified and cannulated with a 5-French feeding tube without difficulty. The right ureteral orifice was also identified. Dissection was then performed to free the left ureter from the surrounding detrusor. There was exceptional fibrotic reaction, however, and this intravesical dissection was unsuccessful. The ureter was entered during the dissection and I made the decision to perform extravesical dissection. The Bookwalter was rearranged to allow visualization of the left perivesical space. Dissection was commenced and it was noted that there was a very large amount of hard stool throughout the colon. This filled the pelvis and made dissection more difficult. The left vas deferens was identified and protected. Because of the difficulty in dissection I asked Dr. Chandler, pediatric surgeon, to come in and assist. We were then able to free the ureter from the surrounding detrusor muscle up to the pelvic brim. During this dissection the Deflux mounds were encountered and removed. Adequate length was then gained for ureteral reimplantation. The ureter was brought in through the posterior aspect of the bladder and a submucosal tunnel created in a Politano-Leadbetter fashion. The ureter was secured in its new location with interrupted 4-0 Vicryl suture. The defect where the left ureter was originally located was significant due to the degree of fibrosis. This was closed with running 2-0 Vicryl suture. The bladder was then closed with 2 layers, the first layer of 2-0 Vicryl followed by a second layer of 3-0 Vicryl. Prior to this, clear efflux was seen from both the right and left ureteral orifices. An 18-French Foley catheter was then brought out through the right side of the abdomen and secured with 3-0 nylon suture. The rectus fascia was closed with running 2-0 Vicryl. The wound then closed in layers with 3-0 and 5-0 Vicryl. A 12-French Foley catheter was inserted per urethra with return of light pink urine. Irrigation of suprapubic catheter showed no significant bladder leak prior to closure of the fascia. The wound was infiltrated with 0.25% Sensorcaine and sterile dressing applied. The patient was awakened and transferred to the recovery room.

Thanks in advance for you help!

Medical Billing and Coding Forum

Closure codes

Please help with the following: Do you code for the complex closure of the lower lid if a flap closure is performed as well?

PREOPERATIVE DIAGNOSES: Open wound of right lower lid, status
post Mohs excision, right lateral canthal laxity, defect of
right cheek, right forearm mass, right wrist mass.
POSTOPERATIVE DIAGNOSES: Open wound of right lower lid, status
post Mohs excision, right lateral canthal laxity, defect of
right cheek, right forearm mass, right wrist mass.
PROCEDURES PERFORMED:
1. Flap closure of right lower eyelid and cheek.
2. Right lateral canthoplasty.
3. Right orbicularis oculi muscle flap.
4. Complex closure of right lower lid, 1.5 cm.
5. Recreation of right lateral lid canthus with adjacent
tissue transfer of 1.5 cm2.
6. Excision of right forearm mass, 1.2 cm superficial.
7. Flap closure of right forearm.
8. Excision of right wrist mass, 1 cm deep.
9. Intermediate closure of right wrist.
10. Right supratrochlear, right supraorbital and right

Medical Billing and Coding Forum

Laparoscopic Closure of Peritoneum Post Hernia Surgery

Please help resolve a dispute. One coder believe that this should be billed 44620 another 49329. Any input would be appreciated.

OPERATION PERFORMED:

1. Diagnostic laparoscopy.
2. Reduction of internal hernia.
3. Closure of peritoneum.

PREOPERATIVE DIAGNOSIS: Small bowel obstruction.
POSTOPERATIVE DIAGNOSIS: Small bowel obstruction.

DESCRIPTION OF PROCEDURE: We used the same infraumbilical 5 mm incision and
reopened the incision. Due to his recent surgery, we used the same opening to
enter a 5 mm port with a blunt tip. Once the port was entered, insufflation was
obtained. Two additional ports were placed initially 5 mm on the left and right
side of the umbilical port. On initial evaluation, the patient had a loop of
small bowel going into the peritoneum, which appeared to be herniated through
the peritoneal defect, even though it appeared that the peritoneum had split
open. Using 2 blunt graspers, we were able to reduce the small bowel out of
this defect and evaluate the small bowel which appeared viable and pink. The
small defect which measured roughly 1 cm was closed with intracorporeal suture
using 3-0 Vicryl suture, using a figure-of-eight suture. In order to do that,
we did have to insert a 12 mm port on the left side. Next, we evaluated for any
other defect and we did not find any other issues, so at this time desufflation
was achieved and the fascia of the 12 mm was closed with interrupted
figure-of-eight Vicryl suture. The skin of all the incision was closed with 4-0
suture. Local was injected. Sterile dressings and Dermabond were placed over
the skin incisions. All sponge, needle and instrument counts were correct at
the end of the procedure.

Medical Billing and Coding Forum

Debridement and Secondary complex closure of wound dehiscence of bilateral breasts

Assistance needed in coding this case for our ASC.

The physician wants to code as 11010 X 2 & 13160 X 2; however, those codes bundle leaving us with just 13160 as the procedure was performed in the same anatomical site.

My question is, would it be appropriate to code 13160 and 19340 LT for the extra work that went into the left side with the implant being removed, cleaned and replaced?

Pre/Post Op Dx: Bilateral incisional dehiscence of breast reconstruction, status post bilateral mastectomy and immediate reconstruction.

Procedures Performed:
1. Debridement of bilateral breast
2. Secondary complex closure of wound dehiscence of bilateral breast

Indications and Findings:
Patient approximately one month status post bilateral mastectomy and immediate reconstruction using AlloDerm and a permanent implant. Today in followup, she was noted to have dehiscence of her incisions bilaterally. On the right, she remained with viable muscle at the base of her dehiscence; however, on the left, there was exposure of her underlying AlloDerm, and is now returned to the operating room for a secondary closure and attempted salvage.

On the right, the patient was noted to have incisional dehiscence; however, the pectoralis muscle remained viable at the base of the wound. There was no evidence of purulence. On the left, there was exposure of the underlying AlloDerm covering the implant. However, again, there was no evidence of purulence or significant infection. On the left, the wound was initially profusely irrigated with a Pulsavac irrigation system. The implant was then removed, and the entire wound again thoroughly irrigated, and the implant was soaked in Betadine for approximately 25 minutes. The implant was replaced and the wound secondarily approximated as described below.

Description: After anesthesia, the left breast wound was then cultured following which the anterior chest wall was prepped and draped in the usual sterile fashion. Nonviable tissue along the margins of both incisions were sharply debrided. Both wounds were then irrigated with the Pulsavac irrigation system using a betadine saline solution. On the right, the patient was noted to have viable pectoralis muscle at the base of the area of dehiscence; however, on the left, there was exposure of the acellular dermal matrix. The matrix was transected at the area of dehiscence and the implant removed. Again, there was noted to be no evidence of any purulence whatsoever within the pocket. The implant was completely submerged in a betadine solution following which the pocket on the left was again irrigated with a Pulsavac irrigation system. The entire operative field was then broken down and reprepped and draped in the usual sterile fashion. The pocket on the left was then again irrigated with 3 liters of a betadine/saline solution following which the implant was replaced within the pocket. The dehiscence was then approximated using interrupted sutures of 3-0 Vicryl to approximate the acellular dermal matrix in deep subcutaneous tissues. The wound was again irrigated with the Pulsavac irrigation system and the skin approximated using interrupted horizontal mattress sutures of 3-0 Prolene. On the right, the wound was reapproximated using interrupted horizontal mattress sutures of 2-0 Prolene. A sterile dressing consisting of xeroform gauze and Tegaderm was applied following which the patient was taken to the step-down unit in stable condition. All counts were correct. There were no complications.:confused::confused:

Medical Billing and Coding Forum