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Official Description

Treatment of superficial wound dehiscence; with packing

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Wound dehiscence refers to the reopening or splitting of a wound along the line of sutures, which can occur post-surgery or after an injury. This condition necessitates careful management to promote healing and prevent infection. The treatment involves cleansing the wound to remove any debris or contaminants, which is crucial for reducing the risk of infection. In some cases, the edges of the wound may be trimmed to promote bleeding, which can help in the healing process by encouraging the formation of new tissue. The procedure associated with CPT® Code 12021 specifically addresses the treatment of superficial wound dehiscence through a method known as packing. Unlike the simpler closure methods described in CPT® Code 12020, which involve sutures, staples, or tissue adhesives, the approach for CPT® Code 12021 involves leaving the wound open and filling it with sterile gauze. This packing technique is particularly indicated for wounds that show signs of infection, as it allows for drainage and helps to manage the wound environment. Once the infection has been adequately treated and resolved, a secondary closure may be performed to complete the healing process.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

Wound dehiscence treatment is indicated in the following scenarios:

  • Superficial Wound Dehiscence This condition occurs when a surgical or traumatic wound reopens along the suture line, necessitating intervention to promote healing.
  • Infection The presence of infection in the wound is a critical indication for packing, as it helps manage drainage and creates an environment conducive to healing.

2. Procedure

The procedure for treating superficial wound dehiscence with packing involves several key steps:

  • Step 1: Wound Cleansing The first step in the procedure is to thoroughly cleanse the wound. This is essential to remove any debris, necrotic tissue, or contaminants that could impede healing or exacerbate infection.
  • Step 2: Trimming Wound Edges If necessary, the edges of the wound may be trimmed to initiate bleeding. This step can promote the formation of granulation tissue, which is vital for healing.
  • Step 3: Packing the Wound After cleansing and possibly trimming the wound, sterile gauze is used to pack the wound. This packing is particularly important for infected wounds, as it allows for drainage and helps to control the wound environment.
  • Step 4: Monitoring and Follow-Up The wound must be monitored regularly to assess for signs of healing or further infection. Once the infection has resolved, a secondary closure may be performed to complete the healing process.

3. Post-Procedure

Post-procedure care involves regular monitoring of the wound for signs of infection or complications. The packed gauze should be changed as needed to maintain a clean environment and promote healing. Patients may require follow-up visits to assess the wound's progress. Once the infection is resolved, a secondary closure can be performed to finalize the healing process. It is important to provide instructions for wound care at home, including signs of infection to watch for and when to seek further medical attention.

Short Descr TX SUPFC WND DEHSN W/PACKING
Medium Descr TX SUPERFICIAL WOUND DEHISCENCE W/PACKING
Long Descr Treatment of superficial wound dehiscence; with packing
Status Code Active Code
Global Days 010 - Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6A - Minor procedures - skin
MUE 3
CCS Clinical Classification 171 - Suture of skin and subcutaneous tissue
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
RT Right side (used to identify procedures performed on the right side of the body)
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional 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/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
A1 Dressing for one wound
AG Primary physician
AM Physician, team member service
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CR Catastrophe/disaster related
GC This service has been performed in part by a resident under the direction of a teaching physician
GW Service not related to the hospice patient's terminal condition
LT Left side (used to identify procedures performed on the left side of the body)
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
SG Ambulatory surgical center (asc) facility service
T5 Right foot, great toe
T6 Right foot, second digit
TA Left foot, great toe
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2024-01-01 Changed Short Description changed.
Pre-1990 Added Code added.
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