# Exploration of Scalp Lesion



## shellott (Jan 7, 2010)

I am looking for some guidance on how to code an exploration of a scalp lesion that was not excised.  The general surgeon (not a derm) thought the lesion was a sebaceous cyst however after making the incision the lesion turned out to be a bony mass.

Should this just we code this as an office visit or as an Incision and Drainage with Modifier 52?


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## Susan (Jan 7, 2010)

shellott said:


> I am looking for some guidance on how to code an exploration of a scalp lesion that was not excised.  The general surgeon (not a derm) thought the lesion was a sebaceous cyst however after making the incision the lesion turned out to be a bony mass.
> 
> Should this just we code this as an office visit or as an Incision and Drainage with Modifier 52?



Since no procedure was actually done, there was no drainage, I would just code an office visit.  I was wondering though, why your surgeon did not continue and just remove the mass?


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## shellott (Jan 26, 2010)

*exploration of scalp lesion*

Thank you for the reply.  I forgot to mention that this service was performed in the ASC.  Any thought on how to code the service?


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## FTessaBartels (Jan 26, 2010)

*For whom are you coding?*

So are you coding for the physician or for the facility?

Can you post the scrubbed operative/procedure note?

F Tessa Bartels, CPC, CEMC


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