kdsampson
Networker
Not sure if this is something that I can legitimately bill for.
Pt complained of a mass in her forearm that appeared after a distal radius fracture. Dr. states at the beginning of his operative report "After the fracture she noticed a soft tissue mass just proximal to this and wanted em to look at it and see if it was something that could be removed. At that point, I would be happy to look at it but it looked like a muscle herniation and if that was the case then there would be nothing we could do with it."
He further states "An incision was made through the skin and subcutaneous tissue revealing fascia. Directly underneath the fascia it was clear that this was a muscle hernation. Exploration around the muscle herniation revealed no cyst or any other softi tissue mass. The wound was copiously irrigated and closed using #4-0 Nylon in an interrupted fashion."
My question, would it be ok to bill for a soft tissue mass removal with modifer 53 since there was no soft tissue mass, or since he already indicated that he thought it was a herniated muscle would this not be billable? Patient was scheduled for a carpal tunnel release, Dr. checked out the mass during the carpal tunnel surgery. Mass wasn't explored through same incision that carpal tunnel release was done.
Thanks for any input!
Kimberly
Pt complained of a mass in her forearm that appeared after a distal radius fracture. Dr. states at the beginning of his operative report "After the fracture she noticed a soft tissue mass just proximal to this and wanted em to look at it and see if it was something that could be removed. At that point, I would be happy to look at it but it looked like a muscle herniation and if that was the case then there would be nothing we could do with it."
He further states "An incision was made through the skin and subcutaneous tissue revealing fascia. Directly underneath the fascia it was clear that this was a muscle hernation. Exploration around the muscle herniation revealed no cyst or any other softi tissue mass. The wound was copiously irrigated and closed using #4-0 Nylon in an interrupted fashion."
My question, would it be ok to bill for a soft tissue mass removal with modifer 53 since there was no soft tissue mass, or since he already indicated that he thought it was a herniated muscle would this not be billable? Patient was scheduled for a carpal tunnel release, Dr. checked out the mass during the carpal tunnel surgery. Mass wasn't explored through same incision that carpal tunnel release was done.
Thanks for any input!
Kimberly