Urology Coding Alert

Question: A patient presents with a non-healing surgical wound from a past nephrectomy in 2006. The patient has diabetes. The doctor is going to do an exploration of a draining sinus of the left flank. Would 20102 be appropriate? Or does this code only apply to an injury such as gunshot or knife wound?

Michigan Subscriber

Answer: You should code this procedure according to what your urologist found, and what he did at the time of surgery. If he found and drained a chronic abscess located in the retroperitonium, then report code 49060 (Drainage of retroperitonel abscess; open).

If your urologist just excised the fistula or draining sinus to its origins in the flank, you should then use code 11043 (Debridement; skin, subcutaneous tissue, and muscle) with the diagnosis of fistula to the skin (686.9).

Why not 20102? A code from the 20100-20103 (Exploration of penetrating wound [separate procedure] ) range will often be your best choice to describe exploration of "penetrating" wounds. Generally, explorations of this type occur when the patient has experienced penetrating trauma, such as a stab wound, gunshot, etc.