General Surgery Coding Alert

Reviewed on May 6, 2015 Question: Our surgeon drains breast seromas using a large syringe. This is technically not an incision and drainage procedure, but the only available breast code (19000) specifies Puncture aspiration of cyst of breast, and we are not aspirating a cyst, either. I think 10160 describes the procedure best, but that code description does not include seromas. What should I do?

Minnesota Subscriber

Answer: Although the descriptor does not include the term seroma, 10160 (Puncture aspiration of abscess, hematoma, bulla or cyst), as you suggest, does best describe drainage of seroma using a syringe. You’re correct to assume that the process you describe is neither an incision and drainage (10140, Incision and drainage of hematoma, seroma or fluid collection) nor a cyst aspiration (19000, Puncture aspiration of cyst of breast).
 
Keep in mind that such drainage often occurs following a recent surgery, and as such, your surgeon may perform the puncture aspiration during a surgical global period. To bill for 10160 as a post-op procedure that is not part of the global period’s normal, uncomplicated follow-up care, you should add an appropriate diagnosis code to indicate the complication. For instance, under ICD-9, you could report 998.13 (Seroma complicating a procedure), which crosswalks to T88.8XXA (Other specified complications of surgical and medical care, not elsewhere classified, initial encounter) under ICD-10. Adding this diagnosis will help support your claim by showing the payer that the drainage is due to complication of an earlier surgery.