General Surgery Coding Alert

Question: My surgeon performed an excision of chronic draining right groin sinus tract. The patient had an inguinal hernia repair with a non-healing surgical wound. After the surgeon excised the sinus tract, he repaired the wound in layers. In the body of the operative note it states that an elliptical incision was made around the chronic draining area and it was completely excised down to the area of fascia including the subcutaneous tissue, and then closed. The surgeon left a drain in place. What code would you suggest?

North Carolina Subscriber

Answer: You should report this repair using 13160 (Secondary closure of surgical wound or dehiscence,extensive or complicated).

Remember: Complex repairs (13100-13160) involve more than layered closure, such as extensive undermining, stents, or retention sutures. Complex repairs may be reconstructive and include creating a defect to be repaired (for instance, scar excision with subsequent closure). The repair you describe qualifies as a complex repair.

Pointer: Layers alone do not determine the level of wound repair. A complex repair requires more than just a multi-layer closure. If you wish to report complex repair codes (13100-13160), the documentation should state that the surgeon corrected a defect or performed extensive tissue debridement.