Otolaryngology Coding Alert

Question: Our physician recently removed a glass splinter from a patient’s neck. When I look 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 is and what code I need to report for this procedure that our physician performed. What should I report?

Idaho Subscriber

Answer: The first thing you need to do before choosing one of the codes that you have mentioned is to check if your clinician performed an incision to access 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 your physician performed an incision, 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’s notes to see the level of difficulty your clinician had to overcome to remove the foreign body, including whether he did any exploration of the wound and whether the wound was infected. You can choose the complicated code if your clinician had to spend a lot of time and effort in removing the foreign body. So, if the documentation says “extensive exploration” or “use of visualization and localization techniques such as X-ray or CT,” then you could be justified in using 10121. Also, look for wound closure as another aid to determine between “simple” and “complicated.”

Plus: Report 10021 over 10020 if multiple foreign bodies were in the same relative area and the physician had to apply complicated efforts to remove these foreign bodies.  As an example, had the glass splinter had to be removed in multiple pieces, it might have qualified as complicated.  Had the glass splinter lodged deeply into subcutaneous tissue, potentially into muscle or tendon, it would also then qualify for a complicated removal.

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 removal was. 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.