Wiki Exploration at right medial scapula

[ammontagano]

Physician thought there was a mass over right scapula and planned surgery to remove it. After the incision was made. there was no evidence of a mass lipoma to be found. How would this be billed as it is now a type of exploratory surgery? Thanks

 

[MSUEEMBRY]

exploration with no mass found

I have the same situation, physician did exploration of periscapular area, muscle was split, dissection carried down to ribcage, but no mass was found, no abnormalities found, no biopsy done. Incision was closed.

Now I am unsure how to code this. Thinking about unlisted CPT 23929 OR cpt 23076 with 52 modifier.

 

[FTessaBartels]

23076 - 53 modifier

I would use 23076 because that was the intended procedure. I would add -53 modifier because due to intraoperative findings, the procedure was terminated.

Hope that helps.

F Tessa Bartels, CPC, CEMC