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ED Coding and Reimbursement Alert

You Be the Coder:

Look within before assigning a penetrating trauma code

Published on Tue Aug 23, 2011

Question: A patient presents to the emergency department after he cut the tip of his finger off while removing the grass catching attachment from his lawnmower. In addition to the E/M documentation, the chart notes read as follows: "13:51 Hemostasis: Moderate amount of left phalanx of 3rd and 4th digits. Controlled using cauterization of both digital arteries of 4th digit, gel foam. Bleeding stopped." Can I report code 20103 for this service?Alabama SubscriberAnswer: Code 20103 (Exploration of penetrating wound [separate procedure]; extremity) is located in the Wound Exploration --" trauma (e.g. Penetrating gunshot, Stab Wound) section of CPT®. The injury caused by a lawn mower blade does not accurately describe a wound exploration of penetrating trauma. Since there is no actual mention of closure in the chart note provided, you would have to default to an E/M code to report your work.Not all traumatic amputations are that straightforward, some do [...]
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