06/06/2018

Correcting Coding for Dorsal Right Foot Hematoma Drained with 27 Gauge Needle

A patient presents with a dorsal right foot hematoma.I drained with a 27 gauge needle. How is this coded?ICD and CPT. Thank you.

Code Description: The CPT code that would be billed for the procedure is 10140 (Incision and drainage of hematoma, seroma or fluid collection).  

Lay Description:            

The physician makes an incision in the skin to decompress and drain a hematoma, seroma, or other collection of fluid. A hemostat bluntly penetrates the fluid pockets, allowing the fluid to evacuate. A latex drain or gauze packing may be placed into the incision site. This will allow the escape of any fluids that may continue to enter the pocket. A pressure dressing may be placed over the region. Any drain or packing is removed within 48 hours. The incision can be closed primarily or may be left to granulate without closure.

Coding Tips:

Hematomas, seromas, or fluid collections can result from trauma or postoperative complications. These fluid-filled pockets can cause infections or lead to permanent erosion of bone and/or cartilage. Removal of a drain is not reported separately. If tissue is transported to an outside laboratory, report 99000 for handling and/or conveyance. Any local anesthesia is not reported separately. When image guidance is performed, report 10140 with 76942, 77012, or 77021, depending on modality. Surgical trays, A4550, are not separately reimbursed by Medicare; however, other third-party payers may cover them. Check with the specific payer to determine coverage.

More information would need to be given to determine the appropriate diagnosis code to link for this procedure.