Post Operative Wound Care

 “I was consulted on a patient in hospital with a large 5th metatarsophalangeal joint ulceration. There was osteomyelitis of the proximal phalanx and metatarsal head. I performed the resection and subsequently performed a delayed closure several days later. The closure left an area open due to soft tissue deficit. This necessitated post operative wound care. I initially billed CPT 28810 and then subsequently CPT 13160. I billed CPT 11042 weekly post operatively, until the wound healed. The private insurance states that all the CPT 11042 billings are considered part of the global. Is there a modifier for submitting related charges for necessary services?”

Let’s first take a look at the players (aka CPT codes) involved:
CPT 28810 is defined as the following: Amputation, metatarsal, with toe, single. This is a major surgical procedure/CPT code with a postoperative global period of 90 days.
CPT 13160 is defined as the following: Secondary closure of surgical wound or dehiscence, extensive or complicated. This is a major surgical procedure/CPT code with a postoperative global period of 90 days.
CPT 11042 is defined as the following: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq. cm or less. This is a minor surgical procedure with a postoperative global period of 0 days.

So, due to the presence of osteomyelitis, the 5th metatarsal head and the proximal phalanx of the 5th toe were resected/amputated supporting the billing of CPT 28810. Subsequently, delayed closure of the surgical site was performed and billed using CPT 13160. This delayed, secondary closure of the surgical site resulted in an open area that required follow up, postoperative wound care that was performed on a weekly basis using CPT 11042 postoperatively until the wound at the surgical site closed.

The health insurance carrier, which apparently was a commercial health insurance carrier, rejected the claims that were submitted for CPT 11042. The rationale for the rejections was the billing of CPT 11042 was considered to be part of the global period. What is one to do?

Well, based upon the billing of CPT 28810 and CPT 13160 within days of each other, there exists two, overlapping 90 day postoperative global periods. I am making the assumption that CPT code 13160 was reimbursed due to the fact that it was stated within the operative report for CPT 28810 that delayed closure of the surgical site at point “X” in the future is “staged, related and pre-planned.” This would justify billing CPT 13160 appended by the 58 modifier. The 58 modifier is defined as the following: STAGED OR RELATED SURGICAL PROCEDURE (“STAGED, RELATED, PREPLANNED”) – It may be necessary to indicate that the performance of a procedure or service during the postoperative period was planned or anticipated (staged). This would allow for reimbursement of CPT 13160 at the full reimbursement value and not initiate a new 90 day postoperative global period.

With respect to CPT 11042, based upon the scenario in the above post, there is no indication that the need to provide postoperative wound care was staged, related, pre-planned. It appears that the surgical site needed to be excisionally debrided of necrotic subcutaneous tissue due to the presence of a postoperative complication. If this was indeed the case, each time that CPT 11042 was billed, it would have been appropriate to append the CPT code with the 78 modifier. The 78 modifier is defined as the following: UNPLANNED RETURN TO THE OPERATING/PROCEDURE ROOM BY THE SAME PHYSICIAN FOLLOWING INITIAL PROCEDURE FOR A RELATED PROCEDURE DURING THE POSTOPERATIVE PERIOD – It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure.

This is my opinion.

Michael G. Warshaw, DPM, CPC

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