tci General Surgery Coding Alert - 2019 Issue Q4

Reader Question: Code Suspected Wound Infection

Question: A patient returned to our surgeon’s office following a hernia procedure complaining of drainage at the incision site. The surgeon incised over the existing umbilical surgical site. The notes reads: “The wound was examined. There was no drainage from the wound. There were no signs of an ongoing or previous wound infection. The sub-q and fat appeared healthy, soft, non-edematous, and non-inflamed. We even attempted to aspirate pus, with nothing on aspiration.” He then irrigated one last time and closed the incision he made. The surgeon stated that the patient may have had an allergy...

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