how to bill procedure/ aspiration/ injection

Messages
103
Best answers
0
MD is trying to bill Ganglion cyst aspiration 20612 for this. He doesn't ever clearly say it is a ganglion. what would be the appropriate procedure code?

I saw ***** regarding a lesion on the dorsum of his right index finger.
He has had a thickening of tissue over the past several months. He
noted that the digit occasionally is more swollen. The lesion is over
the index PIP joint. The patient denies any locking or catching. He
denies any other similar lesions. He is not sure if he may have bumped
the digit.

On examination, there is a 1 cm localized lesion on the dorsum of the
right index finger. The patient has full range of motion of the digit.
The lesion is nontender. There is slight fluctuance, indicating a
possible cyst. At this time, a discussion was made with regards to the
lesion and possible causes. This may be a simple ganglion cyst adjacent
to the extensor tendon. Another possibility is a more solid or soft
tissue lesion, such as a giant cell tumor of tendon sheath. Treatment
options were discussed, and at this time, the patient would like to try
a cortisone injection. Injection and aspiration was performed, and I
did get a slight bit of gelatinouslike reddish fluid; 20 mg of
Depo-Medrol were used as the cortisone component. The patient tolerated
the procedure well. He will monitor his symptoms, and if the lesion
persists, possible excision may be indicated.
 
Top