AHA Coding Clinic® for HCPCS - 2025 Issue 2; Ask the Editor

Evacuation of cheek hematoma

A patient, one day post-cheek reconstruction for melanoma, presented to the emergency room with significant swelling. A hematoma was identified and multiple attempts were made to decompress it under local anesthesia. Some of the clot was expressed, although bleeding was still active. Given the ongoing hemorrhage, the decision was made to perform the procedure under general anesthesia.The patient was taken to the operating room and general anesthesia was administered. The previous incision over the right eye was reopened, and the hematoma was evacuated using digital pressure and suction. After the clot was removed, red blood was noted within the wound, prompting the full opening and irrigation of the anterior incision. Anteriorly, bleeding was controlled via cauterization and clamping. Superiorly, additional bleeding was observed. The infraorbital corner of the flap remained intact, the temporal and the preauricular incisions were reopened revealing active bleeding from a small arterial tributary branching from the temporal artery. This vessel was clamped and cauterized and hemostatic powder was used applied at the wound base. The incision was sutured and closed in layers.What is the correct CPT code for the evacuation of a cheek hematoma? Additionally, what is the correct code for the control of bleeding via cauterization of a tributary artery in the cheek? ...

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