Urology Coding Alert

You Be the Coder:

In-Office Post-Op Wound Infection Treatment

Published on Wed Mar 19, 2014

Question: We had a patient who was status post bladder sling (still in 90-day global period). The patient had a post-operative wound infection of the vaginal incision. The culture grew out E-coli. What procedure code(s) would be correct? The operative report reads: “Vaginal incision wound exploration with cultures, antibiotic irrigation and wound closure ... we then observed the vaginal incision and no purulent drainage seen. We did use Metzenbaum scissors to gently spread where incision was separated. I was able to probe this incision and did obtain cultures. A red rubber catheter placed up underneath the pubis bone on right and irrigated with antibiotic solution. Repeated on left side. Closed vaginal incision with interrupted 0-Polysorb sutures approximating the vaginal mucosa completely.” The small abdominal incision was not reopened.

California Subscriber

Answer: The billing and coding for these procedures performed in the post-operative global period will depend on the payer involved. This problem would be considered a post-operative infection/inflammatory complication within the global period. As this abscess appears to have been drained in the office, for Medicare you would not be able to bill a separate charge because the payer would include this in the global surgical package and not consider it a separately billable procedure.

For non-Medicare payers that allow billing for evaluation and treatments of complications during the global period of another surgery, report 10180 (Incision and drainage, complex, postoperative wound infection) for the complicated drainage and 12020 (Treatment of superficial wound dehiscence; simple closure) for the secondary vaginal closure.