Orthopedic Coding Alert

Question: My orthopedist evacuated a hematoma at the prepatellar bursa on the left knee. He made an incision to perform this procedure, so I don't think 10160 is correct. Should I report this with 27301 or 10140?

Answer: You should report the incisional hematoma evacuation at the prepatellar bursa with 27301 (Incision and drainage, deep abscess, bursa or hematoma, thigh or knee region) because it more accurately reflects the work your orthopedist performed.

You're correct that 10160 (Puncture aspiration of abscess, hematoma, bulla or cyst) doesn't meet your needs because the orthopedic surgeon made the incision to evacuate the hematoma. Generally, you should reserve this code for when your physician merely punches through the skin with a needle to aspirate a hematoma.

Similarly, 10140 (Incision and drainage of hematoma, seroma or fluid collection) is not correct because you should reserve it for more superficial hematomas, whereas the procedure described is deeper.