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Question: The urologist performed a procedure with operative notes as follows: Following the administration of general anesthesia, the patient was positioned in lithotomy. Sterile preparation and draping were performed on his penis, perineum, and lower abdomen. An incision was made at the most anterior part of the swollen area in the perineum, revealing a clear abscess filled with a significant amount of pus. A culture was taken from this purulent material. A finger sweep was carried out to determine the boundaries of the pocket. It was confirmed that there was no involvement of the scrotum. Sterile scissors were used to gently separate the tissue towards the anus, a process known as undermining. A small vac sponge was trimmed in a scalloped pattern. The cavity was subsequently filled and sealed with an Ioban dressing due to its superior adhesion. The sponge was visible through the plastic dressing, onto which the suction adaptor was affixed. The tubing was handed off and linked to the durable medical equipment (DME) vacuum machine, confirming a successful seal. A Foley catheter was then inserted, and the scrotum was fixed ventrally using tape to preserve a flat perineum to allow for a better seal.

How should I code this procedure? Would I code for the vacuum-assisted closure (VAC) placement separately?

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Answer: Based on the information provided, you should first report 10061 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple) since there was undermining to the anus.

Secondly, you will report 97606 (Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters). The National Correct Coding Initiative (NCCI) bundles 97606 as a Column 2 code with 10061, so you’ll need to add modifier 59 (Distinct procedural service) to the code to indicate a separately identifiable procedure.

Note: Vacuum-assisted closure is also referred to as negative pressure wound therapy. Although there are specific codes for this procedure, it's important to note that your insurance provider may not cover the costs. It's advisable to confirm with your insurance provider whether they view the VAC placement as part of the primary surgical procedure, which would mean you cannot claim it separately.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC