General Surgery Coding Alert

Question: A patient returned to our surgeon’s office following a hernia procedure complaining of drainage at the incision site. The surgeon incised over the existing umbilical surgical site. The notes reads: “The wound was examined. There was no drainage from the wound. There were no signs of an ongoing or previous wound infection. The sub-q and fat appeared healthy, soft, non-edematous, and non-inflamed. We even attempted to aspirate pus, with nothing on aspiration.” He then irrigated one last time and closed the incision he made. The surgeon stated that the patient may have had an allergy to the Vicryl suture, causing a bit of wound drainage. How do I report this procedure?

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Answer: For this procedure, report 10180 (Incision and drainage, complex, postoperative wound infection) for the incision and drainage for a suspected wound infection.

Diagnosis help: Because you should code the results following the procedure and the surgeon doesn’t document any infection in this case, you shouldn’t use an infection code such as T81.41XA (Infection following a procedure, superficial incisional surgical site, …) even though the patient reported drainage. Instead, you should report the code for a not-elsewhere-classified problem with the Vicryl sutures: T85.692A (Other mechanical complication of permanent sutures, initial encounter).