# Post procedural breast hematoma CPT help



## ladymerrell (Jul 13, 2018)

I am having an issue coding the evacuation of a large breast hematoma that developed 2 days after a stereotactic biopsy.  

"Upon entry, there was a large amount of dark clot removed.  The cavity was irrigated and suctioned.  Cautery was used for hemostasis.  Over one hour was spent looking around all areas of the cavity and cauterizing all possible bleeding sites.  There was no obvious one location of bleeding, but several areas of oozing, some were small blood vessels which were grasped with a Debakey forceps and cauterized.   The biopsy incision site tract was opened and explored and all areas along that and the hematoma cavity itself were thoroughly explored, several times irrigating well, then cauterizing any areas of visible oozing.  Arista hemostatic agent was applied all around the cavity and some small pieces of surgicel placed over several areas.  A 10 flat drain was placed in the cavity and secured to the skin with a 2-0 silk suture."  

It seems 10140 doesn't encompass the extensiveness of the procedure.  Dr actually re-opened the wound and actively searched for a source of the bleed for over an hour.  21501 is for neck/chest and the breast isn't really either of those areas.  There are some good codes for exploration of postprocedural hemorrhages (35820), but they are specifically for use on the circulatory system.  Would 10140-22 be the only way to go?

Any insight is appreciated!


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## RyanRaichCPC (Aug 6, 2018)

unfortunately I think that's the closest you are going to get to what I thinkyou are trying to describe.  I would definitely add modifier 22 to make sure the reimbursement more accurately reflects what the doctor should be paid.  You will have to add a modifier -78 as well.


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## khoffman (Aug 8, 2018)

*breast hematoma removal - coding based on  CPT®Assistant December 2014 Volume 24 Issu*

Code 21501, Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax, is appropriate to report for evacuation of this type of postoperative hematoma.  Be sure to append modifier 78.


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