I87.2 - Venous insufficiency (chronic) (peripheral)

Clinical Definition

Seroma is a pocket of clear serous fluid that forms in the body's tissues, typically after surgery or injury. It differs from a hematoma as it contains no blood products, only fluid similar to blood plasma.

Documentation Requirements

• Anatomical Location: Must specify exact site

• Postoperative Status: Document if related to recent surgery

• Chronicity: Acute vs chronic

• Size: Document measurements in centimeters

• Associated Symptoms: Note any pain, swelling, or skin changes

• Treatment Plan: Document aspiration attempts or other interventions

• Healing Status: Normal healing vs delayed/complicated healing

Common Synonyms

• Fluid collection

• Post-surgical swelling

• Tissue fluid buildup

• Clear fluid pocket

Coding Conflicts

Excludes1:

• Hematoma (contains blood)

• Lymphocele (contains lymphatic fluid)

• Abscess (contains purulent material)

Scribing.io Automation

The AI scribe automatically detects:

• Keywords like "clear fluid collection" or "serous fluid"

• Post-procedural timing references

• Anatomical descriptors

• Measurements documented during physical exam

• Treatment methods like "aspiration" or "compression"

When providers mention these elements, the system flags them for CDI review to ensure complete documentation.

Note: For accurate coding, remind providers to specifically document "seroma" rather than just "fluid collection" when applicable.