ED Coding and Reimbursement Alert

Question: A patient presents to the emergency department (ED) several days after a procedure. 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: This qualifies as an incision and drainage (I&D) for coding purposes. Since the ED physician performed a significant, separately identifiable evaluation and management (E/M) service prior to the I&D, you can code for that, too.

On the claim, report the following:

• 10140 (Incision and drainage of hematoma, seroma or fluid collection) for the I&D
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making) for the ED E/M service
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99283 to show that the I&D and E/M were significant, separately identifiable services

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