Urology Coding Alert

Question: A patient had a circumcision, then returned to the OR on the next day for an exploration for postoperative bleeding and a large hematoma. What code should I use for the exploration and drainage of the postoperative hematoma?

Rhode Island Subscriber

Answer: This clinical scenario represents a postoperative complication of a surgical circumcision within a 10-day global period. Bill CPT® code 10140 (Incision and drainage of hematoma, seroma or fluid collection) for the second surgery on postoperative day one.

You should also append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) for the treatment of a complication in the operating room within the global period of the initial surgery and with detailed documentation explaining the reason for reporting a service within the global period.