Outpatient Facility Coding Alert

Question: A patient presented to our clinic for excision of a foreign body from his left hand (a BB from a BB gun). The BB was easily palpated. The physician’s notes stated that the incision for removal was deepened down through subcutaneous tissue. I think procedure code 10120 works, but am having trouble with an accurate diagnosis code. The physician wrote 729.6 and edits for code 10120 only list 914.7 as appropriate. Which is the better choice?

Oklahoma Subscriber

Answer:  Reporting 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) sounds accurate. Remember the code includes suturing.

The diagnosis codes suggested, however, might not be the best choices.

Code 729.6 (Residual foreign body in soft tissue) applies to foreign bodies that have been in place for some time, not a new occurrence. Code 914.7 (Superficial injury of hand[s] except finger[s] alone; superficial foreign body [splinter] without major open wound, infected) applies to a superficial wound that shows infection, and you didn’t mention infection.

If no infection was present, a better diagnosis choice would be 914.6 (Superficial injury of hand[s] except finger[s] alone; superficial foreign body [splinter] without major open wound and without mention of infection). Also include E code E922.4 (Accident caused by firearm, and air gun missile; air gun) to document the injury occurred by accident.