General Surgery Coding Alert

Question: A patient presents two weeks after receiving two deep wounds in his upper arm from an exploding propane tank. The patient reports having removed the debris himself, and the wounds are now healed, but one is painful. The surgeon creates an incision and explores the wound. Finding the debris, the surgeon removes a piece of metal from the deep, intramuscular tissue, then cleans and closes the wound. How should we code this?

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Answer: The correct code for this service is 23333 (Removal of foreign body, shoulder; deep (subfascial or intramuscular)). This code aligns with the anatomic site and the depth of the procedure.

Although you describe the surgeon “exploring” the wound, you should not use a wound exploration code, such as 20103 (Exploration of penetrating wound (separate procedure); extremity). Despite the fact that wound exploration codes include foreign body removal, 20103 is not the appropriate code. Wound exploration describes entering an open wound, as opposed to creating an incision to secure a foreign body.