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Evacuation of Deep Axillary Hematoma

Kirsten Posted Tue 14th of July, 2015 16:35:51 PM

The physician performed a mastectomy with axillary node dissection. The next day the patient was returned to the OR for Evacuation of axillary hematoma. The procedure took almost 2 hours. The physician dissected back down to the subfascial tissues and evacuated a large hematoma and the search for bleeders ensued. The area was confirmed to be hemostatic and they closed. What is the correct CPT code to use for this? This seems much more in depth for a 10140 CPT code. Thank you for your assistance.

SuperCoder Answered Wed 15th of July, 2015 00:32:51 AM

The axilla (or armpit, underarm, or oxter) is the area on the human body directly under the joint where the arm connects to the shoulder. There is no specific code for axillary I&D. You can try CPT code 21501 (Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax) or 23930 (Incision and drainage, upper arm or elbow area; deep abscess or hematoma). Also, do not forget to append modifier -78, Unplanned return to the operating or procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period, to show a return to the operating room to treat the complication during the global period of the previous surgery

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