Primary Care Coding Alert

Question: Our FP recently saw a patient who came in complaining of some discomfort in his finger. The patient said that he was working with wood and felt that a splinter of wood had entered the finger. Our FP explored the wound after making a small incision under local anesthesia but he was not able to find anything. The patient returned the next day with the same complaint. Our physician repeated the procedure through another incision made next to the previous one. Further exploration revealed no foreign body and again sutures were placed to close the incision. Can I report a foreign body removal code even though no foreign body was found in the site?

Texas Subscriber

Answer: Since no foreign body was found at the site, you will be wrong if you report the procedure with a foreign body removal code such as 10120 (Incision and removal of foreign body, subcutaneous tissues; simple). However, since the descriptor to 10120 includes “incision,” you can consider reporting this code with the modifier 52 (Reduced services) attached to it. You should attach documentation with the claim saying that your clinician performed the incision for finding a foreign body but could not find anything.

Alternatively, especially if the payer does not recognize the use of this code with the modifier appended, you may try reporting each encounter with an appropriate level E/M service code such as 99201 (if patient is new) or 99212 (for an established patient) for the first visit. 

During the second visit, check if your clinician performed a history taking (e.g. for instance, if anything has changed since the previous day?).  He would also have performed an examination of the finger prior to the incision, and medical decision making (e.g. decision to do a second incision and exploration, finding of no foreign body, no further follow-up planned). Using these criteria, you can report an appropriate established E/M code for the second visit also.