General Surgery Coding Alert

Answer: The codes for foreign-body removal (10120 and 10121, Incision and removal of foreign body, subcutaneous tissues; simple or complicated) are not the best choice here, especially because the surgeon didn't remove anything. Although you might report 10120/10121 and append modifier -52 (Reduced services), you'll receive a reduction in reimbursement that likely will not reflect the amount of work involved in the exploration, which you specifically note was extensive.

For a penetrating wound (e.g., gunshot or knife wound), you can report exploration codes 20100-20103, depending on location (e.g., 20100, Exploration of penetrating wound [separate procedure]; neck; or 20101, chest). Otherwise, you should select an unlisted-procedure code appropriate to the area of exploration (e.g., 25999, Unlisted procedure, forearm or wrist) and provide supporting documentation explaining the extent of the exploration and the reason for the procedure. The insurer will note the unlisted-procedure code and flag the claim for individual consideration. To help the insurer determine payment, compare the procedure to another, similar procedure of approximately the same extent or difficulty. For example, you might compare exploration of a nonpenetrating wound to that of a penetrating wound at the same location.