HCPro, JustCoding Outpatient - 2015 Issue 5 (February)
Q&A: Reporting excision codes when no tumor found
February 4th, 2015
Q: Is it correct to append modifier -52 (reduced services) to a procedure code when the physician performed the procedure, but did not find a mass? This was unexpected, so the surgeon went deeper into the subcutaneous tissue and still did not find anything. This is the outpatient note for a patient with a history of breast cancer and a new lump on her arm with an indeterminate ultrasound:
Under local anesthesia and sterile conditions, a vertical incision was made over the area of the palpable abnormality. We dissected down beneath the subcutaneous tissues. I could encounter no definitive mass or lesions in this area. We went down to the fascia of her bicep. Her biceps appear normal, and the skin and subcutaneous tissue appear normal. My presumption is that this represented some sort of venous anomaly, and I either popped it or incised it during our entry into the skin, and it is now resolved.
Would CPT® code 24075-52 (excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cm) be correct to report?
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