Wiki Exploration of Scalp Lesion

[shellott]

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?

 

[Susan]

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?

 

[shellott]

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?

 

[FTessaBartels]

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