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how would code this hematoma on the forehead

  1. Default how would code this hematoma on the forehead
    Medical Coding Books
    Patient has a massive hematoma on the forehead after suffering a fall a few weeks ago. A curvilinear incision is made overlying the hematoma at the upper half of this lesion. A very large firm clot is extracted, in fact quite easily. A Penrose drain is placd and the integument is reapproximated with interrupted prolene sutures. The approximate size of the lesion is 6 x 10 cm.
    Would this be coded as an I&D 10140 or excision of lesion. Not sure how to code. Any help would be appreciated. Thanks.

  2. #2
    I would code it as 10140. The documentation clearly shows an "incision" being made and a "drain" being placed. Additionally, to support an excision the documentation would need to show "full thickness removal" or that your doctor excised down to the fat.

    Jess, CPCD

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