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Coding resuture of popped suture post op

High risk patient, diabetic, prior BKA Right, returns following amputation distal phalanx left great toe, 5 days post op. He has popped 2 sutures creating a slight dehiscence. Given wound healing risk, I prepped his foot and inserted 3 simple interrupted sutures. Is this billable either via E/M or suturing?

5 comments

Comments (5)

paulkesselmandpm

Dec 05

CMS recently released a new document regarding the surgical global period. This is an extensive review and should really put to bed how to bill (or not) the many minor incidents most surgeons (of all specialities) need to address in the office

during the global period.

This can be found at:

https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

Additionally, there is a new set of G codes, which which can be used to describe visits performed during the post operative period. Dr. Freedman will be explaining them shortly.

Edited

davidfreedmandpm

Nov 06

If Medicare, then yes for digit amputation, has a zero-day global, note that not all private insurance has gone from 90 day global to zero.
If zero day global they are not post-op visits, they are E/M so must document both evaluation and management after the amputation to get an E/M.
I agree it was unexpected, so make sure your operative note in the indications portion documents this and that fact the patient was taken to a "procedure room" or and "operating room" to bill CPT 12020-79 is used for the treatment of superficial wound dehiscence; simple closure.

Alan Bass

Oct 31

In my opinion, this can be coded by either of your approaches. 1) CPT 12020-79 is used for the treatment of superficial wound dehiscence; simple closure; or 2) 99212 with a 24 modifier to indicate that the E&M was performed during the global post-op period (although amputations do not have global post-op period)

Edited

paulkesselmandpm

Oct 31

Replying to

If you billed 28124 then you have a 90 day global that needs to be addressed. The question I would want you to answer, to protect you in case of audit, is there a return to the same type of OR required where the intial procedure was performed? If not, that is problematic.

And can you really document that this was an unexpected complication from the original surgery?

Just performing and documenting what you did w/o referencing that this outcome was not an unexpected complication of the previous sx may result in a recoupment on audit.

My gut feeling here, is that this is actually a compication of the original surgery and that cleaning the wound and putting in three simple sutures is part of the post op experience and there should be no bill.

Your other options are (again with those caviots noted)

Billing the appropriate level e/m w/24 modifier

or biling 12020 with either a 78 or 79 modifier

Bear in mind the following rules for the modifiers:

Modifier 78 is used to report an unplanned return to the operating or procedure room, by the same physician, following an initial procedure for a related procedure during the post-operative period.

Modifier 79 is used to indicate an unrelated procedure that was performed by the same physician or other qualified health care professional during the post-operative period.

Steven Block

Oct 31

Replying to

Billed 28825 for initial amputation of distal phalanx. No global period. I assume follow up visits could warrant an E/M code. I will just use the E/M code.

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Coding resuture of popped suture post op

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