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coding help! exploration of muscle??

  1. #1
    Default coding help! exploration of muscle??
    Medical Coding Books
    MD states incision was made and carried down to the subcu fat. It was carefully palpated to the paraspinal muscle fascia was incised and retractors were placed, The muscle fibers were spread with a hemostat and dissected down to the vertebral body, but all was found was hypertrophied thickend muscle. there is no obvious soft tissue mass or lipoma. Please help, not sure what code best describes what he did since there was no excision.

  2. #2
    If the physician only performed an exploration and did not remove any tissue for a biopsy, then you will need to use an unlisted procedure code from that part of the CPT book, i.e. 22899.
    Judy A. Haroon, RN, BSN, CPC, CGSC

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