General Surgery Coding Alert

Question: The patient underwent a mastectomy. After closing, she developed a large hematoma. The doctor had to return the patient to the OR, reopen the incision and clean out the hematoma. This took about an hour. How can I report this?

Michigan Subscriber

Answer: The correct answer depends on the depth of the hematoma.
 
The most obvious code choice is 10140 (Incision and drainage of hematoma, seroma or fluid collection), but this assumes a fairly simple procedure.
 
Because the surgeon had to re-open the surgical wound to drain the hematoma, a better choice in this case is 21501 (Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax).
 
You might also be able to justify 35820 (Exploration for postoperative hemorrhage, thrombosis or infection; chest), depending on the surgeon's documentation. Because you specifically mention drainage of a hematoma, however, 21501 is still probably the best choice.
 
Regardless of the code you choose, you-ll have to append modifier 78 (Return to the operating room for a related procedure during the postoperative period) to show a return to the OR to treat the complication during the global period of the previous surgery (the mastectomy).