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Open evaluation under anesthesia

K

KARAHUGHES

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Sandpoint, ID
I am searching for a code for an open evaluation under anesthesia. The Dr. initially intended to remove a soft tissue mass but after incision was made he diagnosed the patient with a dilated venous plexus, closed the incision and refferred the patient onto a vascular surgeon. Does anyone know if their is a code for this type of scenario?
 
You are actually looking for a modifier. You would bill the planned surgery CPT and apply a modifier showing the procedure was discontinued. You will need to submit OP report with the claim.

Modifier 53 is used to report a surgery that was discontinued due to extenuating circumstances. If this was in an ASC the modifier would be Modifier 74
 
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