Podiatry Coding & Billing Alert

Question: A diabetic patient presented with a 2 cm ulcer on the plantar surface of the left foot under the second and third metatarsal head. Imaging showed second metatarsal osteomyelitis, and the podiatrist took the patient to the operating room (OR) for surgery for wound debridement with excision of the second metatarsal head. The wound was packed open to be closed at a later date. Two weeks later, the patient returned to the OR for debridement of the wound and closure with a full-thickness skin graft. Which code should I report on my claim?

Georgia Subscriber

Answer: You should report 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated) on your claim. Because this was a planned return to the OR, 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 this procedure.

Don’t miss: Modifier 58 applies to planned procedures, not unplanned procedures. Modifier 58 indicates procedures during the global period that one plans (staged procedures), procedures that are more extensive than the original procedure, and for therapy following a surgical procedure.