Wiki Wound exploration with extension and oversewing

[AR2728]

Please help me! At a loss for billing this procedure, looked at 13160 but wound was packed open

Patient was taken to the operating room and placed in the right lateral
decubitus position and he had his pilonidal wound opened with holding of the gluteal
areas. The wound was found to be opened and at the base there were two sites of
bleeding. The incision overlying the wound was actually extended about 3 cm to allow
for these bleeding sites to be adequately assessed and oversewing with chromic sutures
were done without consequence to aid in complete healing. There did appear to be an
area of still extension of this pilonidal sinus tract that may have to be addressed at a later
date but the wound was then packed open with iodoform gauze and a dry dressing was
applied. Patient tolerated the procedure well and was returned to post anesthetic care unit

 

[AR2728]

Any suggestions?? Perhaps we will have to bill an unlisted procedure code in this instance?

 

[Peter Davidyock]

If this is just an I&D take a look at 10080 & 81.
If it's an excision look at 11770-72.

Looks like a run of the mill I&D. I would use 10080.