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Please help with CPT code!

  1. #1
    Default Please help with CPT code!
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    My doc performed a chest wall hematoma with a capsulectomy.

    REPORT: Dermabond over skin was removed and sutures from PORT-A-Cath removal site were removed. The hematoma was cultured and then evacuated and the pocket was irrigated with normal saline. Capsulectomy was performed. Hemostasis was obtained. The skin had two loose 2-0 nylon sutures placed, as well as a wick in the middle of the incision. The site was cleaned and dressed with a moderate pressure dressing. A 3 pound weight was placed on the patient's L upper chest to prevent any further hematoma formation.

    I have the evaluation code of 10160, but what about the capsulectomy? I can only find the capsulectomy for the breast.

    Thanks in advance for your help!


  2. Default
    If superficial hematoma or abscess your code would go. If it invovled soft tissues of the thorax then i feel 21501 would be appropriate.
    I doubt you can have a capsulectomy code separately for this-hematomas removing ,cleaning or sheath like membrane /pseudocapsule/deep escavation - in other words, could merit to increased work - that is may be appending with modifier 22.

    Does any one have another openion than this .You are most welcome

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