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Subcu Hematoma Remval

cmacpc

Networker
Messages
80
Location
Oakbrook, IL
Best answers
0
Good Morning

Need some help, I have a patient had previous procedure 61312 and 61316 on 1/4/19 and then 1/17/19 patient is taken back to OR for complication: Previous linear skin incision was opened on the right side of abdominal area and subqu dissection was performed. Then the subqu hematoma around skull flap was found and removed. After that careful hemostasis was performed and the surgical field was irrigated with ABX solution. Then the bone flap was placed in the cavity and saved for cranioplasty in the future. The subqu tissue was closed by using Vicryl 2-0 in an inturrupted fashion and the skin was closed subcutaneously with Vicryl 4-0.

I am still kind of new to Neuro so any help would be appreciated.

Thanks,
 

cgaston

Expert
Messages
414
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0
I'll give it a go!


I would select 49002 even though the hematoma does not involve an abdominal organ. The flap was put in the abdominal cavity via open incision, so this is a re-opening of that incision.

As for the dx, I would probably use "other complication of bone graft" T86.838
 
Messages
173
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0
Confusing documentation but I will give it a try.....

Hello cmacpc,

The documentation is confusing to me as it mentions abdominal area and then a skull flap while the CPT's you listed are in the cranial area matching with the skull flap. I am reading this as a subcutaneous post operative hematoma evacuation around the previously placed skull flap area? I am thinking maybe CPT 10140 Mod 78 since it was subcutaneous/no infection? I am totally thrown off by "Then the bone flap was placed in the cavity and saved for cranioplasty in the future." It doesn't seem like the flap was removed? I would recommend questioning/querying the provider for a clearer explanation of what the procedure entailed, that way you can correctly code.

M. Hannus CPC, CPMA, CRC
 

cmacpc

Networker
Messages
80
Location
Oakbrook, IL
Best answers
0
thank you both for your responses I may have to go back to the provider and ask. The documentation is not very clear. Again, thank you
 
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