Anesthesia Coding Alert
Web Space and Mass Exploration
Question: How should I code for "Exploration of first web space, for mass, with exploration of first dorsal interosseous, adductor and volar musculature"? The diagnosis is "Muscular hypertrophy of the first dorsal interosseous muscle and adductor muscle."
Maine Subscriber
Answer: The dorsal interosseous or interosseous dorsalis is a small muscle arising from the metacarpals or metatarsals. Considering this, you first need to find out whether the physician treated the patient's hand or foot. Then you should get more details from the doctor regarding the procedure was a mass found? If so, was it removed?
There is no real "exploration" code, so your best options are fasciotomy or tenotomy. Consequently, you should use CPT 26055 (Tendon sheath incision [e.g., for trigger finger]) or 26045 (Fasciotomy, palmar [e.g., Dupuytren's contracture]; open, partial) with anesthesia CPT code 01810 (Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand) if it was a hand procedure. Use 28008 (Fasciotomy, foot and/or toe) with 01470 (Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower leg, ankle, and foot; not otherwise specified) if it was a foot procedure.
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