SydneyO
Networker
I have a patient who came in a couple months ago for a repair to the Achilles tendon. She just came back in for another procedure because the doctor suspected the wound wasn't healing properly. It sounds from the dictation that when the surgeon opened up the incision and cleaned up the wound, the original Achilles partially re-ruptured so he had to re-do that procedure.
The doctor recorded a diagnosis of "right achilles wound dehiscence and concern for achilles suture issues" and also "partial achilles re-rupture." His operative procedure stated "Open achilles debridement and achilles re-repair."
His description of the procedure said: "The right leg was prepped and draped in the normal, sterile fashion. An incision was made over the right Achilles. The incision was taken down through the skin and subcutaneous tissue. The #5 FiberWire medially were balled up in the area of the wound dehiscence creating fluid. I excised the sutures. This left the Achilles tenuous. I then oversewn the repair with running, locking #5 FiberWire once again. This held quite nicely. I then thoroughly irrigated the wound and injected the wound with 0.5% Marcaine with epinephrine. I closed the skin with 0 Vicryl, 3-0 Vicryl, and 3-0 nylon. I placed a bulky, sterile dressing."
How do I code this? I was thinking diagnosis code T81.32XA for the wound dehiscence but I'm not sure on the CPT code. I also don't know if we should code for the achilles repair and put a repeat procedure modifier on it? I'm guessing we also put a modifier 78 on there?
Any recommendations? Thank you so much in advance!!!
The doctor recorded a diagnosis of "right achilles wound dehiscence and concern for achilles suture issues" and also "partial achilles re-rupture." His operative procedure stated "Open achilles debridement and achilles re-repair."
His description of the procedure said: "The right leg was prepped and draped in the normal, sterile fashion. An incision was made over the right Achilles. The incision was taken down through the skin and subcutaneous tissue. The #5 FiberWire medially were balled up in the area of the wound dehiscence creating fluid. I excised the sutures. This left the Achilles tenuous. I then oversewn the repair with running, locking #5 FiberWire once again. This held quite nicely. I then thoroughly irrigated the wound and injected the wound with 0.5% Marcaine with epinephrine. I closed the skin with 0 Vicryl, 3-0 Vicryl, and 3-0 nylon. I placed a bulky, sterile dressing."
How do I code this? I was thinking diagnosis code T81.32XA for the wound dehiscence but I'm not sure on the CPT code. I also don't know if we should code for the achilles repair and put a repeat procedure modifier on it? I'm guessing we also put a modifier 78 on there?
Any recommendations? Thank you so much in advance!!!