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Basics of drainage/evacuation of Hematoma CPT codes

Drainage or evacuation of hematoma has different techniques. For each technique the CPT codebook has specific procedure code. Yes, for each joint site, their is a separate CPT code for evacuation of hematoma. Depending on different technique and depth of the exam, different CPT codes are assigned after having complete support from the documentation.

For example, the puncture aspiration of a cyst or hematoma fluid done using a syringe needle is reported with cpt code 10060 while the same exam if performed using a drainage catheter under guidance is reported with cpt code 10030. Let us checkout these procedure codes in detail.

Difference between hematoma evacuation CPT code 10030, 10140 & 10160

10030 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous

In this exam, a fluid collection in the soft tissue, such as a hematoma, seroma, abscess, lymphocele, or cyst, is drained using a catheter. The area over the abnormal tissue is cleansed and local anesthesia is administered. Imaging is performed to assist in the insertion of a needle or guidewire into the fluid collection. Small tissue samples may be collected from the site for pathological examination. A catheter is inserted to drain and collect the fluid for analysis. More imaging may be performed to ensure hemostasis. In some cases, the catheter may be attached to a drainage system to allow for further drainage over the course of days. Once the fluid has completely drained, the catheter is removed. A bandage is applied. Report 10030 for each fluid collection drained using a separate catheter.

Since the procedure code includes the guidance, hence do not report CPT code 10030 in conjunction with 75989, 76942, 77002, 77003, 77012, 77021

Use CPT code 10030 for each individual collection drained with a separate catheter

When the hematoma evacuation procedure includes the incision , then the procedure code leads to CPT code 10140 for other specified or unspecified sites. For joint sites, we have specific CPT codes for hematoma drainage/evacuation using incision which we will study later.

10140 Incision and drainage of hematoma, seroma or fluid collection

In this exam, the physician makes an incision in the skin to decompress and drain a hematoma, seroma, or other collection of fluid. A hemostat bluntly penetrates the fluid pockets, allowing the fluid to evacuate. A latex drain or gauze packing may be placed into the incision site. This will allow the escape of any fluids that may continue to enter the pocket. A pressure dressing may be placed over the region. Any drain or packing is removed within 48 hours. The incision can be closed primarily or may be left to granulate without closure.

10160 Puncture aspiration of abscess, hematoma, bulla, or cyst

During this exam, the physician performs a puncture aspiration of an abscess, hematoma, bulla, or cyst. The palpable collection of fluid is located subcutaneously. The physician cleanses the overlying skin and introduces a large bore needle on a syringe into the fluid space. The fluid is aspirated into the syringe, decompressing the fluid space. A pressure dressing may be placed over the site.

If imaging guidance is performed used CPT code 76942, 77002, 77012 & 77021 depending on the documentation.

For evacuation of sublungual hematoma, CPT code 11740 is reported.

11740 Evacuation of subungual hematoma

During this exam, blood from a hematoma located beneath a fingernail or toenail is drained. The nail plate is pierced using an electrocautery tool or large gauged needle creating a large enough opening to allow the hematoma to drain. Pressure may be applied to the nail bed to force the blood from beneath the nail plate. Gauze, a bandage, or a splint may be applied to allow for continued drainage.

Drainage/evacuation of hematoma from soft tissues of neck or thorax is reported with CPT code 21501. The hematoma or fluid is drained from deep soft tissues of the neck or thorax.

21501 Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax

In this exam, the physician performs surgery to remove or drain an abscess or hematoma from the deep soft tissues of the neck or thorax. With proper anesthesia administered, the physician makes an incision overlying the site of the abscess or hematoma of the neck or thorax. Dissection is carried down through the deep subcutaneous tissues and may be continued into the fascia or muscle to expose the abscess or hematoma. The incision may be extended if the mass is larger than expected. The abscess or hematoma is incised and the contents are drained. The area is irrigated and the incision is repaired in layers with sutures, staples, and/or Steri-strips; closed with drains in place; or simply left open to further facilitate drainage of infection. Use CPT code 21502 if a partial rib ostectomy is performed during this procedure