Internal Medicine Coding Alert

You Be the Coder:

Differentiate Between Simple and Complicated Procedures For FBR

Published on Thu Aug 27, 2015

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Question: Our internal medicine specialist recently removed a glass splinter from a patient’s foot. When I am looking at options for removal of a foreign body, I am seeing two options, 10120 and 10121. I am not too sure about what the difference between the two codes are and what code I need to report for this procedure that our physician performed?

Texas Subscriber

Answer: Primarily, the first thing you need to understand before choosing one of the codes that you have mentioned is to check if your clinician performed an incision to reach out to the foreign body. If no incision was done, then you cannot report either of the codes for the foreign body removal. In such a scenario, you will only be able to report an appropriate E/M code for the service.

If an incision was performed, only then you can report either 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (…complicated). For you to differentiate between “simple” and “complicated,” you will need to check your physician notes to see the level of difficulty your clinician had to overcome to reach out to the foreign body, whether or not he did any exploration of the wound and if the wound was infected. You can choose the complicated code if your clinician had to spend a lot of time and effort in reaching out to the foreign body. So, if documentation says “extensive exploration” or “use of visualization and localization techniques such as X-ray or CT,” then you would be justified in using 10121. Also, look for wound closure as another aid to determine between “simple” and “complicated.”

CPT^® Assistant (December 2006, page 15) states, “The choice of code is at the physician’s discretion, based on the level of difficulty involved in the incision and drainage procedure.” Therefore, check your physician’s notes to learn how extensive the removals were. That will guide you to either 10120 or 10121.

Note: If in doubt about whether to choose 10120 or 10121 even after going through your clinician’s notes, you can query your physician to see which of the codes is the better choice for the procedure performed.