Urology Coding Alert

Question: My urologist saw a patient with a suspected infection of an interstim device. The surgeon took the patient to the operating room where he incised over the IPG device on the patient’s lower back. The notes reads: “The wound was examined. There was no drainage from the wound. There were no signs of an ongoing or previous wound infection. The sub-q and fat appeared healthy, soft, non-edematous, and non-inflamed. We even attempted to aspirate pus, with nothing on aspiration.” He then irrigated one last time and closed the incision he made. The urologist stated at the end that the patient may have had an allergy to the Vicryl suture used at the time of the implant, causing a bit of wound drainage. How do I report this procedure?

Alaska Subscriber

Answer: For this procedure, report 10180 (Incision and drainage, complex, postoperative wound infection) for the incision and drainage for a suspected wound infection.

Diagnosis help: You should use the reason for performing the procedure as the diagnosis, so report T81.41XA (Infection following a procedure, superficial incisional surgical site, …) and add Z71.1 (Person with feared health complaint in whom no diagnosis is made) to indicate that the provider did not find an infection.