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Official Description

Incision and drainage of hematoma, seroma or fluid collection

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 10140 refers to the procedure of incision and drainage of a hematoma, seroma, or fluid collection. This procedure is typically performed when there is an accumulation of blood, serum, or other fluids in a specific area of the body, which can cause pain, swelling, and potential infection. The term 'hematoma' refers to a localized collection of blood outside of blood vessels, often resulting from trauma, while 'seroma' denotes a similar collection of clear fluid that can occur post-surgery or injury. The procedure involves making a precise incision with a scalpel to access the fluid collection, allowing for effective drainage. During this process, any clotted blood is removed using a hemostat to ensure that the area is clear of obstructions. To promote continued drainage, gauze packing or a cannula may be employed, especially if there is a risk of fluid re-accumulation. After the drainage is complete, a pressure dressing is typically applied to the site to control bleeding and support healing. Depending on the clinical situation, the incision may either be closed with sutures or left open to heal naturally through secondary intention, which allows for the body to fill in the wound with new tissue over time.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 10140 is indicated for the following conditions:

  • Hematoma - A localized collection of blood outside of blood vessels, often resulting from trauma or injury.
  • Seroma - An accumulation of clear fluid that can develop after surgical procedures or injuries, typically in the subcutaneous tissue.
  • Fluid Collection - Any abnormal accumulation of fluid in a body cavity or tissue space that may require drainage to alleviate symptoms or prevent complications.

2. Procedure

The procedure for incision and drainage of a hematoma, seroma, or fluid collection involves several key steps:

  • Step 1: Preparation - The area surrounding the hematoma, seroma, or fluid collection is prepared by cleansing the skin to reduce the risk of infection. This may involve the use of antiseptic solutions to disinfect the site.
  • Step 2: Incision - A scalpel is used to make a precise incision over the area where the fluid has accumulated. The incision is typically made at the most dependent part of the collection to facilitate effective drainage.
  • Step 3: Drainage - Once the incision is made, the physician drains the fluid by allowing it to flow out of the incision. Any blood clots present within the cavity are removed using a hemostat to ensure that the area is clear and to promote complete drainage.
  • Step 4: Additional Drainage Measures - If necessary, gauze packing or a cannula may be inserted into the cavity to facilitate further drainage, especially if there is a risk of fluid re-accumulation. This helps to keep the incision open and allows for continuous drainage of any remaining fluid.
  • Step 5: Dressing Application - After the drainage is complete, a pressure dressing is applied over the incision site. This dressing helps to control bleeding and provides support to the area as it begins to heal.
  • Step 6: Closure - Depending on the clinical judgment of the physician and the specific circumstances of the case, the incision may be closed with sutures or left open to heal by secondary intention, allowing the body to fill in the wound naturally.

3. Post-Procedure

Post-procedure care for patients who have undergone incision and drainage of a hematoma, seroma, or fluid collection typically includes monitoring the incision site for signs of infection, such as increased redness, swelling, or discharge. Patients may be advised to keep the dressing clean and dry, and to follow up with their healthcare provider for further evaluation and management. Pain management may also be addressed, and patients should be instructed on signs that would warrant immediate medical attention, such as excessive bleeding or worsening symptoms. The recovery process may vary depending on the extent of the procedure and the individual patient's healing response.

Short Descr I&D HMTMA SEROMA/FLUID COLLJ
Medium Descr I&D HEMATOMA SEROMA/FLUID COLLECTION
Long Descr Incision and drainage of hematoma, seroma or fluid collection
Status Code Active Code
Global Days 010 - Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Hospital Part B services paid through a comprehensive APC
ASC Payment Indicator Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6A - Minor procedures - skin
MUE 2
CCS Clinical Classification 168 - Incision and drainage, skin and subcutaneous tissue
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
T5 Right foot, great toe
TA Left foot, great toe
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
T6 Right foot, second digit
T7 Right foot, third digit
GW Service not related to the hospice patient's terminal condition
T8 Right foot, fourth digit
T1 Left foot, second digit
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
T3 Left foot, fourth digit
T2 Left foot, third digit
T9 Right foot, fifth digit
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GC This service has been performed in part by a resident under the direction of a teaching physician
T4 Left foot, fifth digit
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
55 Postoperative management only: when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number.
56 Preoperative management only: when 1 physician or other qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
74 Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
81 Minimum assistant surgeon: minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CG Policy criteria applied
CR Catastrophe/disaster related
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
ER Items and services furnished by a provider-based, off-campus emergency department
ET Emergency services
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
FA Left hand, thumb
FS Split (or shared) evaluation and management visit
GA Waiver of liability statement issued as required by payer policy, individual case
GF Non-physician (e.g. nurse practitioner (np), certified registered nurse anesthetist (crna), certified registered nurse (crn), clinical nurse specialist (cns), physician assistant (pa)) services in a critical access hospital
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
GZ Item or service expected to be denied as not reasonable and necessary
KX Requirements specified in the medical policy have been met
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
PO Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
Q7 One class a finding
Q8 Two class b findings
Q9 One class b and two class c findings
SG Ambulatory surgical center (asc) facility service
TL Early intervention/individualized family service plan (ifsp)
X1 Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2024-01-01 Changed Short Description changed.
2018-01-01 Changed AMA guideline removed.
Pre-1990 Added Code added.
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