Orthopedic Coding Alert

Question: The patient underwent a hemi-arthroplasty for a fractured hip. He returned to the nursing home and 60 days later (still in the global period) fell, resulting in dehiscence of surgical wound. He was readmitted for incision and drainage (I&D) of the wound. Is this a related procedure or an unrelated procedure?

Karole Lee, Clinic Administrator
Helena Orthopaedic Clinic, Helena, Mont.

Answer: Although there may be some disagreement here, the I&D would be coded as a related procedure, since it is done to repair a dehiscence of the wound from the surgery. Even though the fall was technically the cause of the problem, the problem is related to the original surgical procedure. Assuming that your surgeon closed the wound dehiscence, report 13160 (secondary closure of surgical wound or dehiscence, extensive or complicated) with modifier -78 (return to the operating room for a related procedure during the postoperative period). Use diagnosis code 998.3 (disruption of operation wound).