Cardiology Coding Alert

Question: My cardiologist performed a BIV ICD pocket hematoma evaluation and exploration. The antibiotic was completely infused. The patient was prepped and draped in the usual sterile fashion, and the left upper chest was anesthetized with 10cc of 50/50 mixture of 0.25% Marcaine and 2% Lidocaine. An incision was made in the deltopectoral groove and electrocautery was used to dissect down to the device pocket where the pocket was incised. The pre-pectoralis hematoma was evacuated, and it was small. The subpectoral device pocket was explored, the large pocket hematoma was evacuated, and the pocket was irrigated, indicating no active oozing. The device was not required to be delivered from the pocket. Irrigation returned clear pocket irrigation. The pectoralis was reapproximated with interrupted 0-ethibond. The pre-pectoralis space was irrigated with hemostasis. The incision was closed in three layers — the lower two with running 2-0 Vicryl and the cutaneous with 4-0 Vicryl. Steri-Strips and a dry sterile dressing were placed over the wound, and the patient was transferred to the post-anesthesia care unit (PACU) in stable condition for recovery from anesthesia. The device was pacing normally throughout. No reprogramming was performed because it remains as previously programmed. What code should I report for this service? My cardiologist didn’t relocate the pocket.

North Carolina Subscriber

Answer: You should report 10140 (Incision and drainage of hematoma, seroma or fluid collection)

Don’t miss: A hematoma is a swelling or mass of blood confined to an organ, tissue, or space; caused by a break in a blood vessel.