Post-Op Seroma Can Result in I&D Encounter
Question: A patient presents to the emergency department (ED) several days after a procedure performed by another physician in another practice. The patient reports localized swelling and discomfort at the surgical site. The ED physician determines that the patient has a postoperative seroma. After examining the site, the physician makes a small incision over the collection, evacuates the fluid, irrigates the area, and applies a dressing. How should I report this encounter? Illinois Subscriber Answer: On the claim, report 10140 (Incision and drainage of hematoma, seroma or fluid collection) for the incision and drainage (I&D). ICD-10-CM alert: Your question doesn’t provide enough detail to pinpoint diagnosis code selection. You should go back and check the notes, then choose the appropriate postoperative seroma or other complication code from ICD-10-CM based on the underlying procedure and documentation. A good place to start looking is the L76.3- (Postprocedural hematoma and seroma of skin and subcutaneous tissue following a procedure) code subcategory. Keep in mind that if the collection relates to a prior procedure and the patient is within a global surgical period, additional modifier and global period considerations may apply. Michelle Falci, BA, M Falci Communications LLC, Contributing Writer
