Cherie Posted Mon 12th of October, 2015 10:58:39 AM
The doctor did an scrotal drainage, evacuation of pyocele and scrotal orchiectomy. Later that day, the Dr. had to go back in to do an inguinal exploration and over sewing of bleeding vessels. He went back in and opened the incision back up and found a tense hematoma, he opened this up and oblique muscle was pushed up but no fascia. He put a retractor in and identified the stump of the two packets of the spermatic cord that he tied off previously. Each of those packets were bleeding. He clamped and over sewed those areas with suture ligatures. he then irrigated the scrotum and opened the scrotal incision more and got the hematoma out. I would think I would use 54700 for the scrotal hematoma, but not sure of what to use for the over sewing. Would appreciate any help. Thanks!
SuperCoder Answered Tue 13th of October, 2015 04:34:20 AM
Well, there is no need for separate procedure code for over sewing for the scenario. For over work during the procedure, append modifier 22 for increased procedural services with the procedure code. Attach the full operative report with the claim to justify over work. And also append modifier 78 (unplanned return to the OR). Hope it helps!