General Surgery Coding Alert

Question: A 54-year-old female patient underwent a laparoscopic cholecystectomy seven days ago. Subsequently the IV site became red and swollen and developed a hematoma. Is a hematoma a related complication or is incision and drainage (I&D) of a hematoma billable in this situation? A hospital nurse, not the surgeon, placed the IV just prior to surgery.

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Answer: The hematoma is not considered a complication of the surgery and is not directly related to the lap chole that was performed. Therefore, even though the I&D of the hematoma (10140, incision and drainage of hematoma, seroma or fluid collection) was performed during the 90-day global period, it is separately billable, says Jan Rasmussen, CPC, a general surgery coding and reimbursement specialist and president of Professional Coding Solutions in Eau Claire, Wis. Modifier -79 (unrelated procedure or service by the same physician during the postoperative period) should be appended to 10140 to indicate the procedure is unrelated and should not be included in the global period.

If the decision to drain the hematoma resulted from the visit, the appropriate level evaluation and management (E/M) code can be billed with modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) appended. The E/M code can be billed (with modifier -24) regardless of whether the hematoma is surgically removed.

The diagnosis for the E/M visit and/or the surgery should relate to the hematoma, not the original lap chole. Similarly, the documentation of the visit and/or hematoma removal should not refer to a routine postoperative visit but rather should specifically note the new problem (i.e., the hematoma).