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Exploration of Scalp Lesion

  1. #1
    Location
    Everett, Washington (20622)
    Posts
    27
    Default Exploration of Scalp Lesion
    Medical Coding Books
    I am looking for some guidance on how to code an exploration of a scalp lesion that was not excised. The general surgeon (not a derm) thought the lesion was a sebaceous cyst however after making the incision the lesion turned out to be a bony mass.

    Should this just we code this as an office visit or as an Incision and Drainage with Modifier 52?

  2. #2
    Default
    Quote Originally Posted by shellott View Post
    I am looking for some guidance on how to code an exploration of a scalp lesion that was not excised. The general surgeon (not a derm) thought the lesion was a sebaceous cyst however after making the incision the lesion turned out to be a bony mass.

    Should this just we code this as an office visit or as an Incision and Drainage with Modifier 52?
    Since no procedure was actually done, there was no drainage, I would just code an office visit. I was wondering though, why your surgeon did not continue and just remove the mass?
    Susan Ward, CPC, COC, CPC-I, CEMC, CPCD, CPRC
    AAPC ICD-10 Expert Trainer
    susanwardcpc@live.com

    A small act of kindness a day can make someone's day special

  3. #3
    Location
    Everett, Washington (20622)
    Posts
    27
    Question exploration of scalp lesion
    Thank you for the reply. I forgot to mention that this service was performed in the ASC. Any thought on how to code the service?

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default For whom are you coding?
    So are you coding for the physician or for the facility?

    Can you post the scrubbed operative/procedure note?

    F Tessa Bartels, CPC, CEMC

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