Q&A Holy Hernia, CCO!

[Everett]

I could really use your expert opinions on this bugger.
PREOPERATIVE DIAGNOSIS:

1. Incisional infection.
2. Infected mesh.

POSTOPERATIVE DIAGNOSIS:

1. Incisional infection.
2. Infected mesh.

OPERATION:

1. Removal of infected mesh.
2. Drainage of the subcutaneous/abscess.
3. Pulsed irrigation.
4. Repair of the hernia.

ANESTHESIA: General.

This is a 59-year-old male, who 15 days ago, had a repair of umbilical hernia with mesh. He was doing great until 2 days ago, when he started having drainage from the umbilicus. He was found to have purulent brown pus coming out of this. He was scheduled for surgery to open this up and get rid of this mesh.
Gross finding at the time of today's procedure was that the mesh was infected, but there did not appear to be any infection whatsoever down in the intraabdominal portion of the mesh. It seemed to be limited just to the straps from the V Patch. Certainly, the surrounding tissue was infected as well. There was no evidence of any type of a bowel fistula or any injury to the bowel whatsoever. In fact, there were not any adhesions intra-abdominally.
DETAILS OF OPERATION: After appropriate consent was obtained and the patient was identified by myself, he was taken to the OR suite and administered general anesthetic. SCDs were in place preoperatively and functioning appropriately. The abdomen was prepped and draped in usual sterile fashion. A surgical pause was used. His staples are removed. Using finger dissection, we were able to open up the skin. The subcutaneous tissues were cut out. Cultures were taken. First we did irrigate with copious amounts of irrigation. 0-Prolene sutures, which were anchoring the mesh and closing the fascial defect were then cut out. At this point, we just open the fascial defect and removed the mesh. The above findings were noted. Necrotic tissue around the incision was debrided using electrocautery. The incision was then closed with figure-of-eight sutures of #1 Prolene. We then used pulsed irrigation using bacitracin in with the irrigation to the remainder of the wound. Hemostasis was good at this point. The wound was then closed loosely with horizontal mattress sutures using a 3-0 nylon suture. We did place a 0.5-inch Penrose drain underneath of the umbilicus and anchored it to the skin with a 2-0 Prolene suture. Gauze dressing was applied. The patient tolerated this procedure well, which was performed without any complications.

PATH REPORT: GROSS DIAGNOSIS -- HERNIAL MESH

I'm looking to use 10121, 11042, and 10180 as 11005 & 11008 don't seem extensive enough. I know this is a brain strainer, but any thoughts and opinions will be greatly appreciated. Thank you!

 

[Alicia Scott]

Great case. Just a note, thanks for letting us know what you are thinking with the codes. Can you also include where you obtain the case? We want verify it is not a test question. Thanks!!!!

 

[Everett]

This is an actual Operative report under review by my hospital's Coding department. If I had test questions like this to start with, I might have tucked my tail between my legs and RAN! lol

 

[Alicia Scott]

Ha! I agree with you. Ok, so Laureen was on vacation this past week and we need her in on this one. As you know, ICD is my thing. CPT is hers. I can comment but I would rather see what she states. You know we have several really savvy people though. I want to shout out to Tammy, JoAnne and Chandra to put in there combined 2 cents.

 

[joannesheehan]

I would code as following:
This is a return to the OR post 15 days. You would need modifier 78.
10121-78
10180-78
11042-78
Diagnosis code: 998.59 Post-operative wound infection / We should list an infection code but none is listed "as additional" code.
Based on Correct Coding Initiative and RVUs - this is the correct order to code this operative claim.

 

[Tamara Lucus]

Since the infection was due to the mesh and the physician documented necrosis, dx codes would be,

996.69
709.8

I noticed in another response that this is a facility. In my facility I'm only allowed to use certain modifiers, so I'm not adding the modifiers here, but -78 would be the one I would use.

11005- debridement of necrotizing tissue, abdominal wall, with or without fascial closure
11008-Removal of prosthetic mesh

Gross finding at the time of today's procedure was that the mesh was infected...(look at the second paragraph on the op report)

First we did irrigate with copious amounts of irrigation. 0-Prolene sutures, which were anchoring the mesh and closing the fascial defect were then cut out. At this point, we just open the fascial defect and removed the mesh. The above findings were noted. Necrotic tissue around the incision was debrided using electrocautery. The incision was then closed with figure-of-eight sutures of #1 Prolene. We then used pulsed irrigation using bacitracin in with the irrigation to the remainder of the wound. Hemostasis was good at this point. The wound was then closed loosely with horizontal mattress sutures using a 3-0 nylon suture. We did place a 0.5-inch Penrose drain underneath of the umbilicus and anchored it to the skin with a 2-0 Prolene suture.

 

[joannesheehan]

Okay...this is challenging me. Tammy's answer is great. I am seeing Post Diagnosis is incisional infection and mesh infection.

..... when he started having drainage from the umbilicus. He was found to have purulent brown pus coming out of this. He was scheduled for surgery to open this up and get rid of this mesh.
Gross finding at the time of today's procedure was that the mesh was infected, but there did not appear to be any infection whatsoever down in the intraabdominal portion of the mesh. It seemed to be limited just to the straps from the V Patch. Certainly, the surrounding tissue was infected as well. There was no evidence of any type of a bowel fistula or any injury to the bowel whatsoever. In fact, there were not any adhesions intra-abdominally.

Could it be 10180-78 I & D complex post op infection
11008-78

 

[Tamara Lucus]

There was a book that Ingenix put out that had this same surgery in it. How cool is that? This must be a common question.

10180 is used more for an irrigation/biopsy/culture
11005 is used for a debridement and would include the irrigation/culture. It is the more extensive service so it shouldn't be coded with 10180.

Because these two codes are very specific to diagnosis, it would also be appropriate to use the more invasive diagnosis of 996.69. It is assumed that if the mesh is infected the tissue it is laying against would be infected and could spread. If we only coded for the postop wound infection that doesn't encompass mesh.

If you have a subscription to SuperCoder, they have some good examples of when to use 10180 and 11005.

While we would NEVER code based on reimbursement, the RVU's are: 10180 - 6.63, and 11005 - 22.06. That to me indicates that 10180 would be a lesser service, not extensive/invasive at all. If I have the documentation to code for the higher service, I would.

 

[Everett]

Thank you all for your input!