Wiki Please Help! CPT for staged closure of abdomen

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BwitchyCoder

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How would you code this?

The Op Notes are pretty simple....

they basically state -
Pt had complicated AAA repair and need a subsequent bowel resection...
the abdomen was left open and is being closed in stages.
Abdomen was prepped & draped... wound washout and partial closure.

This has happened every 2-3 days for the past week.

Any help would be greatly appreciated.
 
Staged procedures

Since your documentation supports the AAA repair, apply modifier 58 (stage or related procedure...that was your hint) to the procedure. Be certain to note that the physician is the same physican during the postop period.

See definition inside front cover of CPT. Hope this helps.
 
I'm not positive

I'm not certain ... But ...

First your original procedure should have had a -52 modifier (if they knew in advance that the weren't going to close the abdomen) or a -53 modifier (if they decided on the spot that they'd leave the abdomen open)

Then I'd use 13160 w/ a -58 modifier the first time you went back. 13160 with both -76 and -58 modifier for each subsequent time you went back to close the wound.

I know this is usually used for infection or wound dehiscence, so perhaps you'd rather use the complex repair, trunk based on size of repair each time.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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