General Surgery Coding Alert

Question: Several months following partial mastectomy, the surgeon inserted a J-P drain for persistent seroma. How should we report the drain?

Indiana Subscriber

Answer: You should report 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst) because, in this case, the surgeon did not perform an incision and drainage (I&D). Had the surgeon performed I&D of the seroma, you would instead report  10140 (Incision and drainage of hematoma, seroma or fluid collection).

In either case, you should link an appropriate diagnosis (for example, 998.13, Seroma complicating a procedure) to your procedure code.