CPT Knowledgebase - Apr 29, 2024

A 78-year-old female patient undergoes a left, simple mastectomy and sentinel lymph node (SLN) biopsy for extensive ductal carcinoma in situ of the left breast. During postoperative care, the patient develops swelling, pain, and ecchymosis over the left chest wall with copious bloody drainage in the closed suction drain. She is taken back to the operating room (OR) to undergo a surgical evacuation of the hematoma. What would be the appropriate code to report for the procedure, and would modifier 58 or 78 be appended?

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