ED Coding and Reimbursement Alert

Question: A patient presented in the ED with a BB lodged in his hand. The physician made an incision and was unable to find the BB. She then sutured the patient and referred him to a hand surgeon to take care of the BB removal. What code should I report for the physician's incision and exploration of wound? Can I report 10120 if the physician didn't actually remove the foreign body?


Illinois Subscriber
 

Answer: Code 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) specifically requires removal of the foreign body, so the physician must accomplish that to bill the unmodified code. You could append modifier 52 (Reduced services) to 10120 to indicate you had not completed the service as reported.

Alternatively, you could report this service using 20103 (Exploration of penetrating wound [separate procedure]; extremity) from the wound exploration series. These codes do require surgical exploration and enlargement of the penetrating trauma wound to search,but actual removal of a foreign body is not required. The wound exploration codes do carry significant relative value units, so they may not be appropriate for a minor probing and laceration repair.