Internal Medicine Coding Alert

Published on Sun Nov 18, 2012 PDF

Question: A patient came to our office after stepping on a nail. He was afraid some material might still be in his foot. Our physician incised the area but didn't find any type of foreign body or other matter. Can we still charge 28190?

Oregon Subscriber

Answer: Code 28190 (Removal of foreign body, foot; subcutaneous) indicates one factor that doesn't apply to this scenario (foreign body removal) and one that you don't mention (subcutaneous). An alternative choice would be 10120 (Incision and removal of foreign body, subcutaneous tissues; simple). Like 28190, code 10120 involves foreign body removal, which is not applicable, and refers to subcutaneous tissues, which isn't mentioned in your question. Unlike 28190, code 10120 does refer to incision, which your physician performed. If the wound exploration is more superficial, consider using 10120.

In either case, append modifier 52 (Reduced services) since the physician did not actually remove any material. Verify that the physician's notes document the reason for performing the procedure and describe the work done. You can also include a note in Box 19 of the claim form of "no foreign body found" to support using modifier 52.