Question: A patient who underwent several abdominal surgeries in the past presented with a large mass in her abdomen. The surgeon performed exploratory surgery and discovered a large, thick capsule at the subcutaneous level. He then opened the large, thick capsule and evacuated 100 cc of dark blood. He considered this an encapsulated hematoma. Should I use an unlisted-procedure code for the capsulectomy? Can the evacuation of the hematoma be reported separately?
Answer: It is difficult to answer this question in detail without the surgeon's operative report. Excision of lesion codes and intermediate or complex repair codes differ from each other based on size; specifically, excision codes are listed according to size of the mass (after pathology), and repair codes are listed according to size of the defect that is left following excision.
However, we know that the surgeon removed a mass at the subcutaneous level. Therefore, the only code that should be used will be found in the Integumentary System section of CPT .
Codes in the abdominal section apply only to removal of masses inside the abdomen, well below the subcutaneous level. Without the op note, however, we do not know the size of the mass that was excised, the size of the defect or how it was repaired.
If the wound was large, it is likely that some kind of multilayered closure was required. This could be an intermediate (layered) closure (12031*-12037), a complex closure (13100-13102) or a tissue transfer (14000-14001).
If a layered or complex repair is performed, the excision of the capsule could be reported with 11400-11406 (Excision, benign lesion, except skin tag [unless listed elsewhere], trunk, arms or legs ), depending on the size of the lesion.
If a tissue transfer was performed to close the wound, however, the excision is included and should not be reported separately.
Regardless of how the wound was repaired, the exploratory surgery that identified the mass and the evacuation of the hematoma are incidental to the removal/repair and, therefore, should not be reported separately.