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20525/removal of tip of drain

  1. #1
    Cool 20525/removal of tip of drain
    Exam Training Packages
    an ortho surgeon had inserted a drain in the incision from a laminectomy. two days later the surgeon removed the drain, however the tip of the drain did not come out with the tubing of the drain. So the ortho surgeon went back in and removed the tip of the drain.
    basic op note: the patient is a 59-year old female who had surgery 2 days prior. upon removal of her drain it was found that part of the distal aspect of the catheter had not come out clean. i discussed this with the patient and her husband and we elected through return to the operating room for removal of her drain. cephald aspect of our incision was opened using sharp dissection. dissection was carried down to the thoracolumbar fascia. the was incised in the misline on the proximal aspect of the wound. the tip of her drain was noted and this was removed. the wound was irrigated without any complication. closure was commenced with watertight closure of the fascia. subcutaneous tissue was irrigated and reapproximated and staples were once again placed in the skin. sterile dressing was applied. the patient was transferred back to her hospital bed and on to the post anestihesia care unit in stable and satisfactory condition.

    what you would code for this procedure. i chose 20525. ideas??? suggestions???

  2. Default
    20525-58 mod

  3. #3
    Default
    Why the mod 58?

  4. #4
    Location
    Baton Rouge
    Posts
    1,239
    Default
    Quote Originally Posted by pmirolo View Post
    Why the mod 58?
    The modifier is needed so that this second procedure won't be denied as included in global charge of the original surgery. But IMO, should use modifier 78, since the second procedure was not planned, but is related to original procedure.
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default Mod 78
    I agree that the appropriate modifier is -78 ... Unplanned return to OR for a related procedure.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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