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Wiki 10140 vs 10160

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kbarron

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Pt comes in painful toe. Evaluation shows hematoma under lt great toe. Attempte to I&D, discontinued d/t to pt discomfort. Then proceeded to insert needle under skin and a moderate amount of clear to bloody discharge obtained. I am thinking that 10140 should be used. Thanks in advance...
 
If all the documentation is there for the 10160, I would use that. The 10140 was not done and instead the 10160 was done.

Jessica Harrell, CPC
 
Since you mentioned needle insertion and an amount of clear bloody discharge was obtained, I would report 10160...

10160=The physician cleanses the skin above the subcutaneous fluid deposit. A large needle attached to a syringe is guided into the fluid deposit and aspirated with the syringe. A pressure dressing may be applied over the site of the procedure.

10140 requires an incision...

An incision is made with a scalpel and fluid is drained. Any blood clots are removed with a hemostat. Gauze packing or a cannula may be utilized to facilitate further drainage if fluids continue to enter the site. A pressure dressing usually is applied over the site. The incision may be closed, or left open to heal secondarily.
 
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