Primary Care Coding Alert

Question: My physician documented that a tick was embedded in the patient’s abdomen. He anesthetized the area and removed the tick by shaving. His notes don’t mention any type of incision. Can we report the 10120 or 10121 codes?

West Virginia Subscriber

Answer:  No. The removal of an outside element or foreign body (such as a tick, ring, or splinter) from the skin that does not require incision is considered part of the management of the problem; therefore, you should not report a code such as 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (… complicated), which, by definition, requires and incision.  Instead, simply use the appropriate evaluation and management (E/M) code for the encounter.