Wiki How to code removal of cyst not found

[jdibble]

Hi Everyone,

My physician took a patient to the OR to remove a cyst of the left back. After incision through skin and subcu tissue, he did not find a cyst or lipoma as expected. It became obvious that it was acuatly a portion of her Fentanyl pump and a hypertophic scar around the pump. He then proceded to close the incision. He titled the procedure - Wound exploration, but really didn't document any other exploration than the above.

How would this be coded? Any help would be greatly appreciated.

Thanks,
Jodi

 

[MissaBrownlow]

Code Cyst not found

I believe you code the procedure he went in for and use a modifier 52.

Melissa Brownlow, CPC

 

[jdibble]

I believe you code the procedure he went in for and use a modifier 52.

Melissa Brownlow, CPC

Thanks Melissa! That is sort of what I thought, but now the question is which procedure code? He went in to remove a lesion - but since I don't have any sizes since there was no lesion, would I use 11400-52. Or would I consider the procedure foreign body removal, not completed, 10120-52, since it was a scar from the pump? Or another code?

Very confusing!!!