ICD-10 Coding for Seroma(T81.0, T81.4, L76.34)
Complete ICD-10-CM coding and documentation guide for Seroma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Seroma
T81.0-T81.4Primary Range
Complications of procedures, not elsewhere classified
Includes codes for seromas and their complications, such as infection, following surgical procedures.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| T81.0 | Hemorrhage and hematoma complicating a procedure, not elsewhere classified | Use when a seroma develops as a complication of a procedure. |
|
| T81.4 | Infection following a procedure, not elsewhere classified | Use when a seroma is complicated by infection. |
|
| L76.34 | Postprocedural seroma following other procedures | Use for seromas following non-dermatologic procedures without infection. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for postprocedural seroma
Essential facts and insights about Seroma
Primary ICD-10-CM Codes for seroma
Decision Criteria
clinical Criteria
- Presence of seroma post-procedure
Applicable To
- Postprocedural seroma
Excludes
- Infection without seroma (T81.4)
Clinical Validation Requirements
- Documentation of seroma following a procedure
- Imaging showing fluid collection
Code-Specific Risks
- Incorrectly coding as hematoma
Coding Notes
- Ensure documentation specifies the procedure and confirms seroma.
T81.4 - Infection following a procedure, not elsewhere classified
Use when a seroma is complicated by infection.
Applicable To
- Infected postprocedural seroma
Clinical Validation Requirements
- Positive culture or elevated infection markers
- Provider documentation of infection
Coding Notes
Must be sequenced after T81.0 when both are present.
L76.34 - Postprocedural seroma following other procedures
Use for seromas following non-dermatologic procedures without infection.
Applicable To
- Seroma following non-dermatologic procedures
Excludes
- Seroma with infection (T81.4)
Clinical Validation Requirements
- Documentation of seroma following a specific procedure
Coding Notes
Ensure procedure type is documented.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Postprocedural seroma following other procedures
L76.34Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Seroma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code T81.0.
Impact
Clinical: May lead to incorrect treatment decisions., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Always link seroma to a specific procedure, Include procedure date in documentation
Impact
Reimbursement: Incorrect coding may lead to lower reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use T81.0 and T81.4 for infected cases.
Impact
Failure to document procedure linkage can lead to audit findings.
Mitigation Strategy
Ensure all seroma documentation includes procedure details.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Seroma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Seroma
Use these documentation templates to ensure complete and accurate documentation for Seroma. These templates include all required elements for proper coding and billing.
Post-surgical seroma management
Specialty: SurgeryRequired Elements
- Location and size of seroma
- Aspiration details
- Infection markers
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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