General Surgery Coding Alert

Question: What should we do if the surgeon explores a wound for foreign-body removal but finds no foreign body to remove?


New Jersey Subscriber

Answer: For a penetrating wound (such as a gunshot or knife wound), you can report exploration codes 20100-20103, depending on the location the surgeon explores (for instance, 20100, Exploration of penetrating wound [separate procedure]; neck; or 20101, ... chest).

Otherwise, you should select an unlisted-procedure code appropriate to the area of exploration (such as 25999, Unlisted procedure, forearm or wrist) and provide supporting documentation explaining the extent of the exploration and the reason for the procedure. The insurer will note the unlisted-procedure code and flag the claim for individual consideration.

To help the insurer determine payment, compare the procedure to another, similar procedure of approximately the same extent or difficulty. For example, you might compare exploration of a nonpenetrating wound to that of a penetrating wound at the same location.

In either case, steer clear of codes for foreign-body removal (10120 and 10121, Incision and removal of foreign body, subcutaneous tissues; simple or complicated), because the surgeon did not actually remove anything.

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.