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Aspiration of a scrotal hematoma

K

KaylaRieken

True Blue
Messages
527
Location
Waukee, IA
Lidocaine was used to anesthetize the skin and deeper tissue, after which a 20 gauge needle was used to pierce through the right hemi scrotum. I used a 20mL syringe and I was able to aspirate out 160mL of maroon fluid. I then removed the needle and applied a Teflon dressing.

Not sure what to do here. I was looking at 10160 but I'm not sure if this would be correct.
 
10160 seems correct to me.
The provider cleans and isolates the area on the skin and inserts a needle into the fluid deposit area. He then withdraws the fluid or pus through the needle aspiration device. The provider applies antibiotics and dressing. The provider may place a pressure dressing over the area.
I don't see anything in the male genital section that would apply here.
 
Can I still bill for this when the patient is in the post op of a hydrocelectomy and this aspiration happens in the office setting? I am going back and forth on what modifier i can use. 78 does not seem appropriate because it says operating/procedure room.
 
Not my area of expertise (I'm gyn, not male reproductive), but I will assume the procedure is related to the surgery. If so, it is included unless there is a return to the operating room. If the procedure is NOT related to the surgery, then billed with -79.
 
Correct, complications without a return to the operating room are not billable per CMS guidelines.
Medicare includes the following services in the global surgery payment when provided in addition to the surgery:
• Pre-operative visits after the decision is made to operate. For major procedures, this includes preoperative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.
• Intra-operative services that are normally a usual and necessary part of a surgical procedure
• All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room
• Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
• Post-surgical pain management by the surgeon
• Supplies, except for those identified as exclusions
• Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes

Link to full CMS global surgery booklet: https://www.cms.gov/Outreach-and-Ed...oducts/downloads/GloballSurgery-ICN907166.pdf
 
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