Left Groin Exploration

[slwitt]

I would appreciate any assistance for a CPT code. I am thinking it is an unlisted code, but then I have the task of finding a comparison code.

An incision was made above and parallel to the left inguinal ligament. This was deepened through the subcutaneous tissue. Bleeders were clamped and electrocoagulated. The external oblique fascia was incised in the direction of its fibers out through the external ring. The cord was isolated out through the external ring. The ilioinguinal nerve was avoided. I attempted to identify both direct and indirect hernias, neither of which was present. I dissected along the external surface of the external oblique fascia medially for a short distance where she reported her pain and no abnormalities were identified. The external oblique was closed with a running 3-0 Vicryl simple suture. The subcutaneous tissue was closed with a running 3-0 Vicryl simple suture. The skin was closed with 4-0 Vicryl subcuticular buried suture and Dermabond.

[mjewett]

I would code inguinal hernia repair with modifier 52. Most of the work involved in performing and inguinal hernia repair was done; the incision was made, groin explored, and incision closed. It's just missing repairing the hernia. So think it's appropriate to use modifier 52 to indicate this service is partiallly reduced.

Melissa-CPC