Cyst excision / hematoma decompression

rgeib

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Looking for some advice on the following procedure:

"After written consent was obtained from the patient, the skin overlying the 3 x 2.5cm mid forehead soft tissue mass was cleaned with alcohol and injected with 3cc of 1% lidocaine with 1:100,000 epinepherine. The mid forehead was then prepped with betadine and draped with a sterile drape. A scalpel was used to make a fusiform incision around the punctum of the cyst. Scissors were used to dissect the sac of the sebaceous cyst from the subcutaneous tissues until it was removed in its entirety. The wound was then flushed with sterile saline and closed in a layered fashion with 4-0 PDS interrupted sutures to reapproximate the deep dermal layer and 5-0 prolene running subcuticular sutures and 6-0 fast absorbing running sutures on top to reapproximate the skin. The wound was dressed with mastisol and paper tape. The patient tolerated the procedure well. Post procedure instructions were reviewed."

After this, the physician documents that "after he returned home he fell asleep and when he woke up he noticed his forehead was swollen, painful, and oozing...pt returned to the clinic hours after the procedure with a secondary hematoma over the sight." The following is then documented:

"Post procdure hematoma decompressed:
Dressing and sutures removed. The mid forehead was then cleaned with alcohol and injected with 2cc of 1% lidocaine with 1:100,000 epinepherine. The bleeding site was identified and cauterized using a hyfrecator at level 10. The wound was flushed with sterile saline and closed in a layered fashion with 4-0 PDS interrupted sutures to reapproximate the deep dermal layer and 5-0 prolene running subcuticular sutures and 6-0 fast absorbing running sutures on top to reapproximate the skin. The wound was dressed with mastisol, paper tape, and a 4x4 gauze pressure dressing. The patient tolerated the procedure well."

So far, I've come up with 11443 & 12052 for the initial cyst excision and closure. Not sure if the follow-up on same day warrants 10140? Does suture removal & cauterization equate to I & D? Or should I be adding modifier 22 to the first 2 codes? Any help would be appreciated. Thanks in advance.
 

ishtiyaq.ahmad

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I believe its better to code :

T8131XA- Disruption of external surgical wound
L7631- postprocedural hematoma*


CPT 13160 - Secondary closure of surgical wound

"The physician secondarily repairs a surgical skin closure after breakdown of the healing skin. After resolution the wound is now ready for closure. The physician uses a scalpel to excise granulation and scar tissue. Skin margins are trimmed to bleeding edges. The wound is sutured in several layers".

Hope it will work for you :)
 
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