Outpatient Facility Coding Alert

Question: The physician recorded a patient’s diagnosis as ‘knee wound with superficial draining hematoma’. The orthopedist did the following procedure for the patient: irrigation and superficial debridement of knee wound that included evacuation of a hematoma with excision of draining sinus tract. He closed the wound by suture and applied a wound VAC. How should I code for this patient? 

Florida Subscriber

Answer: CPT® 10140 [Incision and drainage of hematoma, seroma or fluid collection] is applicable here because the surgeon incised the hematoma to allow the fluid to evacuate. 

Note that for ongoing maintenance of the wound, report code 97605 (Negative pressure wound therapy (e.g.,  vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters), 97606 (… surface area greater than 50 square centimeters), G0456 (Negative pressure wound therapy, (e.g., Vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 square centimeters) or G0457 (… surface area greater than 50 square centimeters) as appropriate