Urology Coding Alert

Question: My urologist performed a procedure and the operative report reads: “After general anesthesia, the patient was placed in the lithotomy position and his penis, perineum, and lower abdomen were prepped and draped in the usual sterile fashion. An incision was made in the anterior-most aspect of the fluctuant pocket in the perineum. There was an obvious abscess with extensive purulent material, which was cultured. A finger sweep was performed to establish the limits of the pocket. There was no scrotal component. There was undermining of the tissue using sterile scissors to bluntly dissect the tissue toward the anus. I cut a small vac sponge in a scallop fashion. I then packed the cavity and covered it with an Ioban dressing because the adherence is improved. The sponge was exposed through the plastic dressing and the suction adaptor was applied. The tubing was passed off and connected to the DME vacuum machine. A good seal was proven. A Foley catheter was inserted and the scrotum was fixed ventrally using tape to preserve a flat perineum to allow for a better seal.” How should I code this procedure? Would I code for the vacuum-assisted closure (VAC) placement?

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Answer: Based on the documentation provided, you should first report 10061 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple) since there was undermining to the anus.

Then, report 97606 (Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters). The National Correct Coding Initiative (NCCI) bundles 97606 as a Column 2 code with 10061, so you’ll need to report it with modifier 59 (Distinct procedural service) attached to indicate a separately identifiable procedure.

Note: Negative pressure wound therapy is another term for vacuum-assisted closure. While there are codes for this procedure, your payer may not reimburse you for it. Check with your payer to see if they will consider the VAC placement bundled into the main surgical procedure without the ability to separately seek reimbursement.