Podiatry Coding & Billing Alert

Question: A diabetic patient presents with a 2cm ulcer on the plantar surface of his left foot under thesecond and third metatarsal head. Imaging shows second metatarsal osteomyelitis, and the podiatrist takes the patient to the OR for surgery for wound debridement with excision of the second metatarsal head. The wound is packed open and will be closed at a later date. Two weeks later, the patient returns to the OR for debridement of the wound and closure with a full thickness skin graft. Which CPT® code should we report for the second OR visit?

South Carolina Subscriber

Answer: For the debridement of the wound and closure with a full thickness skin graft, you would report 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated).

Notice: You should append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to 13160 because this was a planned return to the OR.