Primary Care Coding Alert

Question: A pediatrician performed a circumcision a newborn in the morning, and the patient came to our office in the evening with bleeding. Our FP had to do suturing to stop the bleeding on the circumcision. How should I code the visit for our FP?

Arkansas Subscriber

Answer: Unlike a regular wound, this is a surgical repair of a surgically created problem, also known as a dehiscence. For the procedure, the FP should code for the simple repair of secondary wound dehiscence with 12020 (Treatment of superficial wound dehiscence; simple closure) It does not sound as if this procedure required packing, so 12021 ( with packing) would be inappropriate.

The ICD-9 coding will reflect that the wound was a surgical dehiscence of the circumcision. Use 998.3 (Disruption of operation wound). If the bleeding was due to infection at the site, use 998.59 (Postoperative infection; other postoperative infection) as a secondary diagnosis.

The FP should also code for a new patient office visit (99201-99205) in addition to the procedure, if there is documentation to support the taking of a history, the examination and the medical decision-making. Append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code because there will be a procedure performed at the same time as the visit.

Answered by Susan Welsh, CPC, PMCI, a coding educator and former billing coordinator for the department of orthopedics at Vanderbilt University in Nashville, Tenn.