General Surgery Coding Alert

Question: Six days ago, a patient underwent a laparoscopic cholecystectomy. Since then, the IV site has become red and swollen and developed a hematoma. Is the hematoma a related complication of the lap chole (and therefore bundled), or is I&D of the hematoma a separately billable procedure?

Montana Subscriber

Answer: In the case you cite, the hematoma is not a complication of the surgery and is therefore not directly related to the lap chole. Therefore, even though the surgeon performed incision and drainage (I&D) of the hematoma (10140*, Incision and drainage of hematoma, seroma or fluid collection) during the 90-day global period of the lap chole, you may bill separately for it. To indicate that the procedure is unrelated and should not be included in the global period, you should append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to 10140.
 
And, if the physician performs and documents an E/M service, you may report the appropriate-level service with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) appended.
 
The diagnosis you choose for the E/M visit and/or the surgery should relate to the hematoma rather than the original lap chole. Again, this is because the hematoma is not a complication of the lap chole. Similarly, the documentation of the visit and/or hematoma removal should not refer to a "routine postoperative visit" but should instead specifically note the new problem, which in this case is the hematoma.