Primary Care Coding Alert

Question: Which code do I use when the doctor says he did an incision and drainage (I&D) of a genital hematoma with a Word catheter? The patient is female.

 

North Carolina Subscriber

 

Answer: Typically, a Word catheter is used to drain a labian lesion after I&D. In this case, the correct code is *10140 (incision and drainage of hematoma, seroma or fluid collection). This code is a starred procedure, so the services provided include only the surgical component.

 

However, if the hematoma is located at another site on the genitalia, two other codes might apply. Code 57022 (incision and drainage of vaginal hematoma; post-obstetrical) or 57023 (& non-obstetrical [e.g., post-trauma, spontaneous bleeding]) These two codes were introduced in CPT 2001.