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deep hematoma

codedog

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NEW ORLEANS
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Confuse on what to code for this procedure . Doctor office says to code this as 10140- I & D of a hematoma, because he did a skin incision, but I think it should be cpt code 27301-I &D of deep hematoma of thigh, because of him stating deep down to the fascia. Who is right ?.

PREOPERATIVE DIAGNOSIS: Deep thigh hematoma.

POSTOPERATIVE DIAGNOSIS: Deep thigh hematoma.

PROCEDURE PERFORMED: Incision and drainage of deep thigh hematoma.

ANESTHESIA: MAC with local.

.

FINDINGS: 150-200 cc organized hematoma involving the fascial and subfascial elements of the right thigh.

DRAINS: 90 mm Blake drain.

PROCEDURE IN DETAIL: After induction with MAC anesthesia, the right thigh was prepped and draped in the usual fashion. A skin incision was made with a skin knife, and using the cautery, the organized hematoma was entered. This extended down deep to the fascia. All the solid elements of the organized hematoma were cleared. Once this was done, cultures were taken. We then proceeded to copiously irrigate the cavity and pseudocapsule. Inspection for bleeding was then performed. The area was hemostatic. A 90-mm Blake drain was brought in through an anterior incision, tunneled in the soft tissues of the inferior portion of the thigh and into the cavity. This was secured with 2.0 Blake drain. Final inspection for bleeding was performed. The incision was then closed in a vertical mattress fashion using 2-0 nylon suture. Sterile dressings were placed. The patient was awakened and transferred to the recovery room in stable condition.
 
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