Wiki Seroma drained & debride retained suture

[RebeccaMoney]

CPT 25028 or 11043? 25028 was authorized but physician gave me 11043.
...A 2cm incision was made in line with the previous incision . Incision was made through skin only. Blunt dissection was carried deeply and about a 1 cm seroma was evacuated. There were small remnants of the previous Vicryl suture that has been placed, which was debrided with a rongeur.
Please help. Thank you,

 

[Orthocoderpgu]

Because the physician did not go past the skin layer, the code is going to be in the integumentary system. Code 25028 is in the M/S system, so that is ruled out. Code 11043 is for the debridement of a wound down to the muscle and fascia level. Once again, documentation does not support work done in the muscle & fascia. Look at 10140. It specifically mentions I&D of a seroma and has more RVU value than 11042.

 

[RebeccaMoney]

10140 certainly seem more correct. It was confusing me that the note stated through skin only but then stated dissection carried deeply. Thank you so much for your help.

 

[Orthocoderpgu]

You have to make your decisions based on documentation. The physician made a point to state that the incision went through the skin only. If the physician went past the skin/sub-q tissue it would need to be documented. This is why coders and physicians need to work together.