Wiki Incision - No Foreign Body Found

[emourer]

Billing as patient's PCP - patient came in for possible foreign body on her foot. 2 cm incision was made. Area clotted with dried blood but no foreign body was evident. Would this be included in the E/M or would it be more appropriate to bill 10120-52? I have been unsuccessful at finding correct billing informtion for this scenario.

Thank you.

 

[LuckyLily]

I had the same situation come up for me and thankfully I got the answer.

In the Coding Clinic for HCPCS-Third Quarter 2007 pg 10

It discusses discontinued procedures vs. unsuccessful procedures. Direct statement "When a procedure is considered to have 'failed,' specifically the expected result of the procedure is not achieved, the procedure is coded as performed."

Modifier 52 would not be appropriate unless it was a discontinued procedure for some reason.
The E/M would depend on the documentation provided.

 

[pedscoder21]

Billing as patient's PCP - patient came in for possible foreign body on her foot. 2 cm incision was made. Area clotted with dried blood but no foreign body was evident. Would this be included in the E/M or would it be more appropriate to bill 10120-52? I have been unsuccessful at finding correct billing informtion for this scenario.

Make sure that the physician documented that the incision was within the subcutaneous tissue (required for CPT 10120).