ED Coding and Reimbursement Alert

Question: I am trying to code a chest exploration following a gun shot wound. Would I use an unlisted procedure code for this?Florida SubscriberAnswer: No, although circumstances would vary depending on the specific case and documentation. The code set 20100-20103 is available to describe surgical exploration and enlargement of the wound, extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or coagulation of minor subcutaneous and/or muscular blood vessel(s), of the subcutaneous tissue, muscle fascia, and/or muscle, not requiring thoracotomy or laparotomy. If the treatment progressed to a full and formal thoracotomy, code 32110 (Thoracotomy, major with control of traumatic hemorrhage and/or repair of lung tear) would be a consideration, as well.Based on your description, we would recommend 20101 (Exploration of penetrating wound [separate procedure]; chest.)Bonus: If the ED physician uses single-layer closure to repair a heavily contaminated wound that requires "extensive cleaning  or removal of particulate [...]