General Surgery Coding Alert

Question: The surgeon treated a patient who evidently had recurring infection at the site of a prior wound closure. The report documents the surgeon opening the prior incision, performing digital manipulation of the site measuring 12 sq cm, finding shallow purulence but healthy tissue at the wound base. The surgeon excised the skin edges with scissors until observing punctate bleeding. The surgeon made a decision for negative pressure wound therapy and instructed the patient for ongoing care. How should we code this?

Ohio Subscriber

Answer: The documentation points to debridement code 97597 (Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less). This code accounts for sharp debridement with scissors for a wound less than 20 sq cm and instruction for ongoing care.

The documented exploration is included in the debridement. Don’t additionally code the wound vac, which is not performed at this session. Because 97597 has 0 global days, you may code the wound vac if/when your provider performs the service on a separate day with no modifier needed.