Jun 2nd, 2016 - nonadianne 6
Skilled Nursing Home Visit
Attending MD goes into see a resident and sees that they have a thrombosed superficial hematoma on the right anterior lower leg that has not coalesced. It has kept her from her normal social activities . She has been on antibiotics and anti inflammatory but it is not resolving.
MD decides to excise this large hematoma removing approximately an ounce of chocolate coalesced material i.e. clots. the patient tolerated the procedure well. Procedure done under sterile techniques and when he had completed the procedure she was dressed and given pain meds to assist with her discomfort.
Question is can I bill for this and if so which modifier would I use. He did a
E/M of a 99308 prior to doing this procedure.
I don't usually get procedures in a nursing home setting, so I really don't know how to code this. Any assistance would be most grateful.