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Need Help with exploration code

  1. #1
    Question Need Help with exploration code
    Medical Coding Books
    This one is throwing me for a loop. Basic run down is that the patient was seen in the ER for a foreign body in the arm. Found to be a needle that broke off. ER attempted to remove it with ultrasound and was unable they called the Ortho MD to try with flouro.
    My MD reopened the incision created by the ER (antecubital fossa) and used the wound to explore the area with needle driver and hemostat. Needle was found to be very superficial by flouroscopy but unable to be visualized. MD exlpored and searched for 1 hour with flouroscopy and did not retrive the needle. MD did eventually isolate the needle to a large scarred knot of the antecubital vein but unable to remove the needle without needing to remove the vein itself. She then aborted the procedure-due to not being comfortable with where the needle was and referred patient to plastics--closed the wound.

    I am wondering if I would code 24200 with the 53 modifer or with the 52 or something different all together.

    Please help. Thanks
    Tina Wosmek CPC, COSC

  2. #2
    It sounds like the wound was only explored so I would go with 20103.

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