Exploration..Help

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Thibodaux, LA
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My physician did and exploration of the left forearm due to believed possible retained foreign body, however, there was no foreign body found during the exploration. The only code I am coming up with for this would be 25248 but that is with removal. Can anyone help with this and a possible dx code?? Any advice is appreciated. The report reads as follows:


PREOPERATIVE DIAGNOSIS: Left forearm foreign body.
POSTOPERATIVE DIAGNOSIS: Normal left forearm exploration.
PROCEDURE: Exploration of left forearm.

NDICATIONS FOR PROCEDURE: This patient is a 37-year-old male who presented with findings consistent with a possible retained foreign body in his left forearm. The risks and benefits of forearm removal including bleeding, infection, pain, scarring, inability to remove foreign body, as well as damage to surrounding formed tissue were all described in detail with the patient, who agreed that undergoing surgery was his best course of care.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in supine position. After general anesthesia was induced, his left forearm was prepped and draped in a sterile fashion and a time-out performed. An incision was made over the area of concern in the left forearm, and blunt and cautery dissection were used to dissect into the subcutaneous tissue of the left forearm. A thorough exploration was performed in this area and no foreign body could be found or palpated. No foreign body was palpated deeper in the tissue and in order to avoid any further tissue damage or deeper structural damage, it was decided to discontinue looking for a foreign body as none could be found. The incision was irrigated and the skin was closed with Monocryl suture. A sterile dressing was placed. The patient was taken out from anesthesia and to the recovery suite in stable condition. It should be noted that mini C-arm was used in the area as well and no radiopaque foreign body was noted within the left forearm.
 
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I would go with that code 25248 and append a 52 modifier. Everything was done for the description of the code, except for the removal of the foreign body
 
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