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need help with CPT and modifier

  1. #1
    Default need help with CPT and modifier
    Medical Coding Books
    procedure: 2nd surgery--removal of packing of left dorsal wrist and hand wound with repeat irrigation of skin, subcutaneous tissue and muscle.

    1st procedure: 25028, I&D of forearm/wrist

    Looking at 11010 with modifier 58

    Cultures were taken prior to irrigation. There did not appear to be any residual purulent material. The skin still appeared to be somewhat irritated with the surrounding cellulitis, but it was improving. The extensor tendons appeared to be intact. There was some trauma to one of the dorsal sensory ulnar nerve branches from the infection, but the nerve itself was still intact. The previous pocket of purulent material extended to the ulnar aspect of the hand over the hypothenar area. No additional skin required sharp debridement, but there were some areas of skin that still looked relatively inflamed and cellulitic. The cellulitis however appeared to be contained. It was not extending up the forearm. After the wound cultures were taken, the wound was thoroughly irrigated with antibiotic solution along the skin, subcutaneous tissue and muscle. The wound was then packed open with quarter inch lodoform gauze. Dry sterile bulky dressing was applied. Patient was placed in a short-arm splint.

    Thanks for any help.

  2. #2
    Per op note, not title of procedure, you can code attention to carrier and your practice's rules.

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