Pediatric Coding Alert

Question: Our pediatrician saw a patient who had been running barefoot on a wooden deck, which resulted in her getting a splinter in her foot. What procedural code should we use, and why?

Florida Subscriber

Answer: The choice of a CPT^® code in this scenario really boils down to the method your provider used to remove the splinter and the complexity of the removal itself.

If your provider was able to remove the splinter simply by using a pair of tweezers, and nothing more complicated occurred during the service, you wouldprobably just use an evaluation and management (E/M) service code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient ...) to document what was done.

However, if your provider documented that the foreign body (FB) removal was simple, but that the removal required an incision to be made in the patient's foot, then the next most obvious choice to document the service would be 10120 (Incision and removal of foreign body, subcutaneous tissues; simple). A more complex removal, involving exploration or debridement of the wound, would be coded with 10121 (Incision and removal of foreign body, subcutaneous tissues; complicated).

A third way to code this, again depending on the depth of the splinter and the complexity of the procedure your pediatrician performed, would be to go with a site-specific surgery code.

In this case, you could use 28190 (Removal of foreign body, foot; subcutaneous). This code indicates, again, that the removal occurred at the deeper, subcutaneous level. Anything deeper than that, for example a splinter that went down to the fascia or bone, would be recorded with 28192 (... deep). And anything that required more than just removal of the FB would also require a different code, such as 28193 (... complicated).

The main difference between the 10120-10121 and 28190-28193 lies in the area of clinical responsibility. As 28190-28193 are surgery codes, they require much more work, including local anesthesia, irrigation, and even wound closure with strips or sutures when appropriate.

Regardless, as the work involved in either 10120-10121 and 28190-28193 indicates that your pediatrician performed an additional service beyond the initial E/M for the patient, you can also report the E/M by using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).