Primary Care Coding Alert

Question: A patient had a head injury but could not have an MRI because of decorative studs in his face. The studs had embedded backs, so required surgical removal. Our physician removed four studs from his facial cheeks, using four separate incisions. I'm looking at codes 10120 and 10121. What is the difference between these, and do I report the correct code four times? Washington Subscriber Answer: You are correct to be choosing between 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) and 10121 (... complicated). When reporting a procedure that qualifies for 10120, the physician makes an incision in the area of the foreign body and uses appropriate instrumentation to remove the foreign body. It is a simple, uncomplicated incision that does not require dissection. Difference: Procedures reported with 10121 involve a more complicated removal process. The physician's notes should indicate extended exploration around the wound site, [...]