Report a Surgical Wound Exam During a High BP Follow-Up
Question: I have a report from a follow-up encounter between a patient and their primary care physician (PCP). The patient recently went to the emergency department (ED) for high blood pressure (BP). The note also mentions that the patient recently had a pilonidal cyst removed. The surgeon left the wound open so it could drain and heal from the inside out. The PCP is doing a culture of the wound to check for infection. What diagnosis codes should I report for the encounter? Missouri Subscriber Answer: Assign I10 (Essential (primary) hypertension) to report high blood pressure as the reason for the follow-up visit. Next, you’ll use Z48.01 (Encounter for change or removal of surgical wound dressing) to report the PCP’s examination of the open surgical wound following the pilonidal cyst removal. The PCP also ordered a culture of the wound to test for an infection. Depending on the depth of the surgery, you’ll assign either T81.41XA (Infection following a procedure, superficial incisional surgical site, initial encounter) or T81.42XA (Infection following a procedure, deep incisional surgical site, initial encounter) if the pathology test is positive for an infection. Mike Shaughnessy, BA, CPC, Development Editor, AAPC
