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Tanesha Posted Wed 29th of November, 2017 14:58:16 PM
Would you just code the excision of the fibrosed sac and not the evacuation of the hematoma? Excerpt: An incision along the anterior portion of the anterolateral aspect of the right lower leg was then incised. She was noted to have a fibrosed sac with retained old hematoma, which was evacuated. The fibrosed sac was then excised and then was copiously irrigated with Asepto syringe. The subcutaneous tissues were then reapproximated.
SuperCoder Answered Thu 30th of November, 2017 08:17:29 AM

Hi,

 

The best way to come out of such issues is that you find out your codes and then check CCI edit. If there is CCI edit between two codes, do not report column 2 code. If there is no CCI edit, bill both codes together. One more thing to note is that you should also check information “Separate Procedure” in the code’s descriptor. If it is present, then you should not report this code (even if there is no CCI edit) because both the procedures have been performed on the same anatomical site via the same incision.

 

Please feel free to write to us if you have any questions.

 

Thanks.

Tanesha Posted Thu 30th of November, 2017 08:29:16 AM
Ok, if there is no edit, then I should be able to code both. I would just have to query on the cm size of the sac, the depth of it and code along with an evacuation of the hematoma, correct?
SuperCoder Answered Fri 01st of December, 2017 00:35:03 AM

Yes, you are correct. If your CPT code requires size, then you must choose your code based on the size.

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