Wiki Need help with CPT code(s)

[daystarjj]

I need help in determining the appropriate cpt codes for control of bleeding (foot) during post op period: Here is the wording of the OP note:
Dehisced area was excised with a 15 blade down to and including the muscle. Multiple small bleeding vessels were located along the skin lines. Larger vessels were noted at the medial aspect of the foot in the central aspect underneath metatarsals 2 & 3. the bleeding vessels were ligated and cauterized. Still excessive amounts of muscular oozing and decision was made to pack the area with Surgicel and Gel-foam and then packed with half inch plain packing.....

Any help would be greatly appreciated THANK YOU!

 

[podcoder70]

To answer this fully, I would need some more history on the patient and the original surgery. Was the incision site left open or was the patient non compliant and busted the area open? How deep is the dehisced area? Was the wound left open on this second procedure or closed? If closed, was it simple or intermediate?

From what I can tell with what you have provided, you now have a wound that needs to be repaired, the ligation and cauterization are included in the wound repair. You will need to determine if this is a simple or intermediate repair then choose from 12001/2 or 12041/2 depending on size. You will then need to add the 78 modifier to indicate this was unplanned. The dx would be T81.31A or 32A for dehiscence of surgical site.

 

[amyjph]

Agree as above, would require more information.

The word dehisced always points me to 13160. However, would need to know all the same things as the poster above mentioned.
You could also consider 12020, 12021 depending on if it is a secondary wound closure and if it was simple or w/ packing. Take a look at those codes.
What was the original surgery?
My opinion is it is not 12001/2 or 12041/2 if it is a surgical wound disruption w/ dehiscence and secondary closure.