Internal Medicine Coding Alert

Question: A patient's bridge wire became imbedded in the underside of his tongue, and the physician removed it. The physician wants to report 10120. Is this correct?

Kansas Subscriber

Answer: Yes. Code 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) is appropriate for this situation. If your internist had to treat an infection in the patient's tongue resulting from the imbedded bridge wire, you can report 10121 (... complicated) because the infection would make it a complicated procedure.
 
Remember: Code 10120 covers both the bridge-wire removal and any repair your internist might have performed. If you report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) along with 10120, your carrier will likely deny the repair code.
 
If your internist performed an E/M examination in addition to the foreign-body removal, you can report the appropriate E/M-level code separate from 10120 or 10121. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to your E/M code to indicate that the bridge-wire removal was separate from the E/M.