Urology Coding Alert

 Question: A patient recently had an open radical nephrectomy. The wound opened and the patient noted exposure of bowel contents. It was decided to surgically close the opening. She underwent a wound exploration, washout, and complex wound closure with ventral inlay mesh. What CPT^® and ICD-10 codes should I use? Should I append modifier 78?

Pennsylvania Subscriber

Answer: According to the documentation you provided, the appropriate procedure code is 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated) and the diagnosis should be T81.31XA (Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter).

If the same surgeon handled both procedures (the radical nephrectomy and the wound closure), you can append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to this claim. Include documentation explaining why the return to surgery was necessary. The placing of the inlay graft is included in the surgical closure code 13160.