AHA Coding Clinic® for HCPCS - 2018 Issue 3; Ask the Editor

Incision and drainage, rectus sheath

A patient with a hematoma of the right rectus sheath presents for incision and drainage. The patient was prepped and general anesthesia was administered. A 5 cm incision was made and dissection was carried down to the subcutaneous fat and the rectus sheath was incised. The fluid cavity was accessed and brown serous fluid was drained. The rectus sheath was explored; a suction device was utilized to evacuate any existing fluid and area irrigated with saline. The surgical area was closed in layers. Would incision and drainage of the rectal sheath hematoma be reported with unlisted CPT code 20999? ...

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