I need help getting started on the right track for coding a healing abdominal surgical wound. This patient had lysis of adhesions two days prior to transfer to another hospital. The patient was transferred for an unrelated condition to the abdominal surgery, nevertheless did receive attention to the wound which included removal of some of the staples. There were no complications of surgery, so where do I start in looking for the proper code for the abdominal wound. Is it considered a laceration and what external code would be appropriate?
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Wiki routine healing surgical wound, subsequent care at second facility
- Thread starter bccoffey
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mitchellde
True Blue
A surgical post operative wound is never a lacyeration. You use a Z code for aftercare following surgery such as staple removal or if there are no issues or wound care then a z code for follow up.
melanieaufderhar
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Maybe look at dx code T81.31XA for Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter.
mitchellde
True Blue
You would only use the code for disruption of wound if it was documented that there was a dehiscence or disruption, not for a routinely healing surgical wound. The original post indicated it was routinely healing and received routine post operative care.