Pediatric Coding Alert

Question: One of our teenage patients was involved in a car accident. She was treated at the emergency room for a laceration of the cheek, but the wound needed no sutures. Several days later, she came to see us believing there were foreign bodies in the wound. Our pediatrician anesthetized the laceration and removed two small pieces of glass after a brief exploration. What procedure code should I use for this?

Pennsylvania Subscriber

Answer: The answer to this really depends on whether your pediatrician made an incision into the patient’s cheek to perform the foreign body removal (FBR).

If your physician removed the glass pieces using just tweezers or forceps, you cannot code for a separate procedure. Instead, you would use an evaluation and management (E/M) code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) commensurate with the level of exam, history, and medical decision making (MDM) involved in the FBR.

FBRs involving incisions, however, have their own codes. Which ones you use will depend on the depth of the foreign body in the patient’s tissue, and the level of complexity involved in the FBR. Depending on specifics, this would mean coding either 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (… complicated) in this particular case.