Pediatric Coding Alert

Question: I spent a while poking at a patient's blood clot to get it to break. I put on protective glasses and a gown. Should I report the incision and drainage using 99213?

Georgia Subscriber

Answer: You can report incising and draining of a hematoma with 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst). Stress to the patient that you are performing a higher-costing procedure, rather than an E/M service.

Code 10160 contains 3.08 relative value units (RVUs) and pays a national rate of approximately $117 compared to 99213's (Office or other outpatient visit for the evaluation and management of an established patient ...) 1.68 RVUs or $64 on the 2008 Medicare Physician Fee Schedule that private payers may adopt. That's a difference of $53 for the same work that you provided.

Beware: If you had drained blood from under the nail, you would instead use 11740 (Evacuation of subungual hematoma), which contains 1.08 RVUs.

An E/M code may also be justified if the physician addresses a separate E/M problem at the same visit, such as associated trauma. To be paid, you should attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code (for instance, 99213-25).