Dermatology Coding Alert

Question: Is it correct to code for removal of multiple foreign bodies in a penetrating wound by reporting CPT codes from the wound exploration (20100 or 20103) category? Can I report the removal multiple times in the same area or should I only report the codes once?

New Jersey Subscriber

Answer: You typically report these codes for patients with a trauma, such as a gunshot wound or stabbing by a sharp instrument. Usually, the physician incises (expands the area) the wound to allow for a better view of the area, and he debrides and explores the wound. If you encounter multiple foreign bodies, then you only report the code once. If the physician repairs major structure(s) or major blood vessel(s) requiring thoracotomy or laparotomy, don't use these codes. Code for the repair to the major structure or blood vessel. To report simple, intermediate or complex repair of wound(s) that do not require enlargement of the wound, use specific repair code(s) in the integumentary system section of CPT (12001-13160). You should code according to body area: 20100 (Exploration of penetrating wound [separate procedure]; neck), 20101 (...chest) and so forth. You would only report each area once.