Primary Care Coding Alert

Question: A patient presented with a puncture wound in the palm of her hand after falling off of her bike. Our FP incised the wound to examine it and clean it copiously, and encountered no sign of infection. How do I code this?


Idaho Subscriber
 

Answer: Use 20103 (Exploration of penetrating wound [separate procedure]; extremity) for puncture wound care of an extremity, such as the hand. Depending on your physician's documentation, you may find it most appropriate to append modifier 52 (Reduced services). 

According to CPT, 20103 relates to the following services provided in conjunction with a wound resulting from penetrating trauma: -explore or enlarge the wound, dissect the wound to determine penetration, remove foreign bodies, debridement, and repair minor blood vessels.-

In this case, your physician clearly completed some of the services described in the descriptor for 20103. However, you make no mention of additional services such as removal of foreign bodies or repair of minor blood vessels.

To properly report a code, the scope of your physician's services should closely approximate the CPT descriptor. Modifier 52 could signal to your carrier that the physician performed a reduced version of the service and that your office is entitled to less than the 14.58 nonfacility RVUs that payers normally grant to 20103.