Wiki removal of foreign body with repair

[KERRIEA]

Child came to pediatrician office with injury to the forehead that happened 2 months ago after a BB gun incident. Mom believes child still has a BB in his forehead. xray was done and circular object noted. procedure notes: "area cleaned with betadine and area injected with xylocaine. 1 cm incision made with scalpel. Area around BB dissected with scalpel and forceps. BB expressed with side and lower pressure. Area closed with 3 5-0 sutures. Hemostasis is good. Dressing applied. BB found in deeper subQ tissue. "

Question: Physician wants to charge for both the incision and removal of the BB as well as the closure. It's my understanding that 10120-10121 would include a closure and would probably be denied by the payer. Is this true? And would this procedure constitute a 10121 vs a 10120?

Thanks!

 

[LindaEV]

The code would include the closure. (if closure was complicated, you could consider billing a repair code instead)

I think you are safe for the 10121. he says it was deep and that he had to dissect surrounding tissue. So it was more than your basic "slice and pluck".

 

[KERRIEA]

Thanks Linda - I appreciate your help with this!!