I performed a open amputation of the first ray left . Gas gangrene 10 days later I return to OR to close the wound. How should I code.?
Based on the situation, the surgery performed in the OR should be billed with CPT 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated). since the patient is within the global period to the amputation, the procedure should be billed with modifier -78, (Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postoperative period ).
13160
Secondary closure of surgical wound or dehiscence, extensive or complicated
Lay Description (Code):
The physician secondarily repairs a surgical skin closure after an infectious breakdown of the healing skin. After resolution of the infection, the wound is now ready for closure. The physician uses a scalpel to excise granulation and scar tissue. Skin margins are trimmed to bleeding edges. The wound is sutured in several layers.
Coding Tips
For packing or simple secondary wound closure, see 12020–12021. If incision and drainage of a hematoma, seroma, or fluid collection is performed, see 10140. It is inappropriate to report supplies when these services are performed in an emergency room. For physician offices, supplies may be reported with the appropriate HCPCS Level II code. Check with the specific payer to determine coverage.