Podiatry Coding & Billing Alert
Remember to Add Modifier 58 to This Claim
Question: A diabetic patient presented with a 3 cm ulcer on the plantar surface of the right 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 initially left open with the intention of closing it in the future. After 14 days, the patient was brought back to the operating room for wound debridement and closure, which was achieved using a full-thickness skin graft. Which code should I report on my claim? Wyoming 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 is used for procedures that are scheduled or anticipated, not for unexpected ones. It signifies procedures performed during the global period that are staged, more comprehensive than the initial procedure, or therapeutic postsurgical procedures. 
Podiatry Coding & Billing Alert
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