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Orthopedic Coding Alert

Reader Question:

Treatment During the Global Period

Published on Wed Mar 01, 2000

Question: A patient who recently underwent back surgery and within the global follow-up period had the back reopened for debridement and irrigation of L5-S1 sic space with 12,000 cc of normal saline. Pre-op and post-op Dx: disc space infection at L5-S1. How should this be coded?

Ramona Marden
Penobscot Bay Orthopaedic Associates, Rockport, Maine

Answer: Susan Callaway-Stradley, CPC, CCS-P, an independent coding expert and educator in North Augusta, S.C., says, Depending on the procedure performed, you might consider the debridement codes, 11040-11044, 10180 (incision and drainage, complex, postoperative wound infection) or 12020-12021 (treatment of superficial wound dehiscence).

If you are using these codes, add a modifier -78 to indicate a return to the operating room. Modifier -78 (return to the operating room for a related procedure during the postoperative period) indicates the physician is taking the patient back to the OR during the global period to treat a complication from the original procedure.
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