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, sometimes with a need to use visualization and localization techniques such as X-ray or CT. The code includes wound closure.

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 removals were. That will guide you to either 10120 or 10121. Report the appropriate code four times because the physician made four separate incisions and the descriptor for each code refers to a "foreign body" (singular).