tci General Surgery Coding Alert - 2002 Issue 5

Reader Question: Removal of Abdominal Mass

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? Texas Subscriber 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...

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