KeraA
New
Good morning! I've recently had an orthopedic doctor start using 15002 for removal of deep scar tissue. I don't feel this is the correct code based on the CPT description because a recipient site wasn't created, however it does say "or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children", so I know he's going to argue with me. I would love to get another opinion on this. Thank you!!
Pre-op diagnosis: 1. Left hip periprosthetic joint infection
2. Left hip draining sinus tract and surgical wound dehiscence
3. Left acetabular abscess
Post-op diagnosis: other (1. Left hip periprosthetic joint infection; 2. Left hip draining sinus
tract and surgical wound dehiscence ; 3. Left acetabular abscess; 4.Left iliotibial band tension
with adhesions)
Operation Performed:
1. Explant of infected left total hip arthroplasty (CPT 27091, modifier 22)
2. Incision and debridement of acetabular bone abscess (CPT 26992)
3. Partial excision and craterization of proximal femur bone (CPT 27360)
4. Manual preparation and placement of articulating antibiotic cement spacer (CPT 20702)
5. Manual preparation and placement of antibiotic beads (CPT 20700)
6. Fasciotomy of iliotibial band and release of subfascial adhesions (CPT 27025)
7. Excision of sinus tract, scar tissue, and complex wound closure (CPT 15002)
8. Secondary closure of surgical wound dehiscence with negative pressure wound vac (CPT 13160)
The patient's prior incision was excised along with the draining sinus tract near the proximal
aspect of the incision. This was carried out using a scalpel and electrocautery and the full
thickness scar was excised down to the fascia. The draining sinus tract led to a deep pocket of
abscess and rent in the fascia. This was also excised and debrided. Hemostasis was maintained using
electrocautery. The rest of the fascia was incised along the line of the skin incision. A posterior
approach was used to enter the joint. The joint fluid appeared purulent and samples were sent for
culture and gram stain. The posterior capsule was identified and an arthrotomy was then created. The
incision was extended distally following the posterior aspect of the greater trochanter. There was
noted synovitis and signs of chronic infection. The hip was then dislocated and the ceramic femoral
head was removed using a Cobb and mallet. There was a titanium sleeve that was also removed from the
Pre-op diagnosis: 1. Left hip periprosthetic joint infection
2. Left hip draining sinus tract and surgical wound dehiscence
3. Left acetabular abscess
Post-op diagnosis: other (1. Left hip periprosthetic joint infection; 2. Left hip draining sinus
tract and surgical wound dehiscence ; 3. Left acetabular abscess; 4.Left iliotibial band tension
with adhesions)
Operation Performed:
1. Explant of infected left total hip arthroplasty (CPT 27091, modifier 22)
2. Incision and debridement of acetabular bone abscess (CPT 26992)
3. Partial excision and craterization of proximal femur bone (CPT 27360)
4. Manual preparation and placement of articulating antibiotic cement spacer (CPT 20702)
5. Manual preparation and placement of antibiotic beads (CPT 20700)
6. Fasciotomy of iliotibial band and release of subfascial adhesions (CPT 27025)
7. Excision of sinus tract, scar tissue, and complex wound closure (CPT 15002)
8. Secondary closure of surgical wound dehiscence with negative pressure wound vac (CPT 13160)
The patient's prior incision was excised along with the draining sinus tract near the proximal
aspect of the incision. This was carried out using a scalpel and electrocautery and the full
thickness scar was excised down to the fascia. The draining sinus tract led to a deep pocket of
abscess and rent in the fascia. This was also excised and debrided. Hemostasis was maintained using
electrocautery. The rest of the fascia was incised along the line of the skin incision. A posterior
approach was used to enter the joint. The joint fluid appeared purulent and samples were sent for
culture and gram stain. The posterior capsule was identified and an arthrotomy was then created. The
incision was extended distally following the posterior aspect of the greater trochanter. There was
noted synovitis and signs of chronic infection. The hip was then dislocated and the ceramic femoral
head was removed using a Cobb and mallet. There was a titanium sleeve that was also removed from the
