Home Health ICD-9/ICD-10 Alert

Question: We are providing care for an elderly male patient who has a hematoma on his leg resulting from a catheter placed in his right femoral artery which ruptured. The hematoma is slowly organizing and approximately 4cm x 10cm x 6cm. It is sometimes pruritic and somewhat painful. How would I code for this patient? Do I need to list an E code to explain the circumstances?

Answer: Hematomas, as well as seromas, can be traumatic or nontraumatic in nature. Such a condition may create pressure on surrounding capillaries, causing hypoxia and tissue death around the hematoma. This condition is considered a compartment syndrome and sometimes results in ulceration. In addition to the compartment syndrome, the hematomas and seromas are great environments for bacteria to grow. At times physicians excise the hematoma to relieve the pressure.

If the hematoma was caused by an accidental puncture during a procedure, then your primary code is 998.2 (Accidental puncture or laceration during a procedure).

Certain complication codes require additional codes to provide more information. Code for the traumatic hematoma next, followed by a compartment syndrome code. No E code is necessary. The acute facility should be reportng the E code for the medical misadventure in this case.