Wiki cpt for postprocedural knee hematoma evacuation

[Rufus186]

Pts presents 2 days post medial retinaculum reefing for patella subluxation with hematoma in the retinaculum.
Proc performed: Arthrotomy hemostasis and wound closure

Procedure detail: I had to undermind the lateral skin with an edge to edge closure (reefing) this is where the hematoma had occurred. We then opened the wound and evacuate a large hematoma from the superolateral aspect of the knee where the lateral release had been performed. Careful inspection showed no major bleeding at this the lateral superior geniculate artery. We irrigated the wound multiple times to be sure the knee was evacuated and decompressed. We did an interrupted vertical mattress closure of the retinaculum until the would was sealed. We put 1/4% bupivacaine with adrenaline intra-articulary and then sutured to leaking areas to confirm that we had sealed the wound. We than ran a strata fix in the deepest layer of the subcutaneous layer.

Im leaning towards 27310 or unlisted but not sure if this documentation supports an Arthrotomy no incision was documented post op wound was reopened, any suggestions would be greatly appreciated!

Thanks

 

[AlanPechacek]

In this case, 27310 would be the most correct, as it would include the treatment of the hematoma as part of the exploration, hematoma debridement/removal, and irrigation. By virtue of the original procedure which included a Lateral Reticular Release, this procedure creates an arthrotomy by its very nature. So, although he did not make a separate incision into the joint, there already was one present. I'm sure his irrigation include washing out the joint through the lateral release incision/wound, which constituted the arthrotomy. You might be able to add Modifier 22 for Increased Procedural Services to cover the extra work done to prevent new/recurrent bleeding/hematoma. Send the Op Report for support.

I hope this helps.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com