Forum - Questions & Answers

Apr 23rd, 2015 - TerryC 39 

tx wound dehisscence help please!

A patient came into the office 4/13/15 and had a lipoma removed from the trunk. He than returned 4/21/15 for a problem with the excision. The wound had opened up on one side. Sutures still in place. There was a blood clot coming out from the wound. The doctor a (different one, but same practice) spent 30-40 minutes removing the blood clot. She than closed just that open part of the wound with steri strips. Is this considered "up and above global"? I thought she could maybe charge a 12021 however this says with infection there was no infection just the clot. Can she charge anything at all maybe a E/M code since closed with steristrips or is there something else she could charge. Thank you.

Apr 23rd, 2015 - petunia 195 

re: tx wound dehisscence help please!

Look at 10140-78 dx 998.12

Apr 23rd, 2015 - TerryC 39 

re: tx wound dehisscence help please!

Thank you I did think of that however the wound was already opened on the one end. She didn't have to open. She just spent the time cleaning out the wound through the already open area.
I saw this under the guidelines.
Follow up care for Therapeutic Surgical Procedures.
Follow-up care for therapeutic surgical procedures includes only that care which is usually a part of the surgical service. Complications, exacerbations,recurrence or the presence of other diseases or injuries requiring additional services should be seperately reported. I think this would apply?
I think she should at least be able to charge an E/M?

Apr 23rd, 2015 - petunia 195 

re: tx wound dehisscence help please!

In that case we normally use the 52 modifier to say the wound was already open so no incision was done. Reduced service. I would add both 52-78 modifies.



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