Orthopedic Coding Alert

Question: After a total knee replacement done three weeks ago, one of our patients developed redness and discharge through the distal aspect of the surgical wound and developed a 2 cm dehiscence. An exploration, irrigation, and debridement of the superficial wound dehiscence was done with delayed primary closure. The dehiscence was a localized one superficially through the subcutaneous tissue without extension into the joint. Is this reported as code 11042 and 13160 or otherwise?

Texas Subscriber

Answer: According to the given description, the wound was repaired. You report code 12020 (Treatment of superficial wound dehiscence; simple closure) with a diagnosis of T81.31xA (Disruption of external operation [surgical] wound, not elsewhere classified, initial encounter).

Since the wound dehiscence is a superficial one, which goes down to the subcutaneous level, code 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) may be appropriate if a significant amount of devitalized tissue was removed. The description here is not elaborate enough to report 11042 along with the repair code. Besides, the Correct Coding Initiative (CCI) bundles code 11042 with 12020.

Code 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated) is not right for this procedure as it does not mention that an extensive or complicated closure was done.