ED Coding and Reimbursement Alert

Answer: CPT Code 10121 (incision and removal of foreign body, subcutaneous tissues; complicated) should be used only when an incision is necessary to remove a foreign body and the physician documents the removal as complicated. To better illustrate when this code would be appropriate, consider the example of a patient who presents with a piece of glass embedded in a wound:

The removal of a sliver of glass not requiring suturing
would be included in the evaluation and management (E/M) code (99281-99285).

To remove glass from an open wound requiring simple
suture, the intermediate repair codes (12031-12057) can
be used.

If the removal of glass from an open wound requires
extensive cleansing and debridement, coders should choose the appropriate debridement code (11040-11044) in addition to the suture code.

For an open wound that requires enlargement and
exploration to remove the glass, use the appropriate wound exploration code (20100-20103), depending on the circumstances. According to CPT, Simple exploration of nerves, blood vessels or tendons exposed in an open wound is also considered part of the essential treatment of the wound and is not a separate procedure unless appreciable dissection is required. If the wound requires enlargement, 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, use codes 20100-20103, as appropriate. Use of 20100-20103 should be restricted to significant wounds requiring exploration and/or removal of foreign bodies.

If removal of embedded glass requires a simple incision,
use 10120* (incision and removal of foreign body,
subcutaneous tissues; simple).

Finally, if removal of embedded glass requires incision
and complicated removal (e.g., extra time needed for small pieces of glass), use 10121 (incision and removal of foreign body, subcutaneous tissues; complicated).

You Be the Coder answered by Laura Siniscalchi, RRA, CCA, CCS-P, CPC, education coordinator for Beth Israel Deaconess Medical Center in Boston; and Caral Edelberg, CPC, CCS-P, president of Medical Management Resources, a training and consulting firm in Jacksonville, Fla.