# Evacuation of abd wall hematoma



## pamley11

I'm needing help with CPT codes please!

The patient below underwent a lap chole and returned to the ER a couple days later for abdominal wall hematoma. The dr describes the procedure as an evacuation of abdominal wall hematoma. 

Op Note:
A subcostal incision was made. Using the cautery, we incised the anterior rectus sheath and almost immediately was a large expression of blood clot. We incised the remainder or the rectus muscle with cautery. Clot and old blood was evacuated throughout the entire length of the rectus sheath. Oozing vessels and oozing from the rectus was controlled with cautery. I incised the posterior sheath and the peritoneum to inspect intra-abdominally and there was no bleeding from here.

The posterior sheath and peritoneum were closed with a running 0Vicryl continuous suture. Hemostasis of the rectus sheath was felt to be excellent. A large Blake drain was placed within the sheath and brought out through a separate lateral insicion, securing it to the skin with a 2-0 silk. The anterior sheath was closed with a running 0 looped PDS continuous suture. The skin was closed with a stapler. 

any help is much appreciated!


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## ajs

pamley11 said:


> I'm needing help with CPT codes please!
> 
> The patient below underwent a lap chole and returned to the ER a couple days later for abdominal wall hematoma. The dr describes the procedure as an evacuation of abdominal wall hematoma.
> 
> Op Note:
> A subcostal incision was made. Using the cautery, we incised the anterior rectus sheath and almost immediately was a large expression of blood clot. We incised the remainder or the rectus muscle with cautery. Clot and old blood was evacuated throughout the entire length of the rectus sheath. Oozing vessels and oozing from the rectus was controlled with cautery. I incised the posterior sheath and the peritoneum to inspect intra-abdominally and there was no bleeding from here.
> 
> The posterior sheath and peritoneum were closed with a running 0Vicryl continuous suture. Hemostasis of the rectus sheath was felt to be excellent. A large Blake drain was placed within the sheath and brought out through a separate lateral insicion, securing it to the skin with a 2-0 silk. The anterior sheath was closed with a running 0 looped PDS continuous suture. The skin was closed with a stapler.
> 
> any help is much appreciated!



49010-78 looks as close as I can figure.


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## Lujanwj

What about 49002-78? Sounds like Dr did a Reopening as described in OpNote "incised the posterior sheath and the peritoneum to inspect intra-abdominally".  Hematoma, debridement, and cautery would all be incidental to the more extensive procedure.  

Good luck!


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## pamley11

I looked at 49010 but it is for *retro*peritoneal exploration and he stayed in the anterior abdominal wall.


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## pamley11

49002 - That would have been my choice except he didn't do a laparotomy on the first surgery. Since the chole was laparoscopic, I didn't think this would apply.


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## Lujanwj

You're right, that didn't register.  Why not 49000 than?  Dr is still entering the cavity and "exploring" for bleeding.  Dr is doing a Laparotomy (however small it is) and 49000 doesn't describe how much exploration needs to be done. 

Good Luck


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## pamley11

I'm thinking you're right. 

Thanks so much for the help!


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## molisa

Thanks for this discussion.  There's been several of these lately that have caused me some trouble, just like what was discussed. 
Here's another issue; would anyone consider the hematoma to be traumatic since the lap chole preceded it?  I've got a hospital coder stating 729.92, but I'm considering using 922.2 with E878.6.


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## colorectal surgeon

I would go with 49000-78 as well. Can't do 49002 and it's not retroperitoneal.  Good case.


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