General Surgery Coding Alert

Question: A piece of wood split and lodged in a construction worker's right forearm. There was a palpable foreign body on the volar aspect of the forearm. The end of the wood was visible at the entrance wound but was tightly wedged against the patient's skin.

The physician sterilized the arm, prepped it with betadine and anesthetized the area with lidocaine. He then enlarged the opening of the entrance wound to free up the end of the sliver. Using a hemostat, the physician removed the wood piece entirely intact. He cleaned the wound but did not close it, and applied dressing.

How should I code this encounter?


Oregon Subscriber


Answer: Because the physician performed an incision to free up the end of the sliver, this qualifies as a soft-tissue foreign body removal (FBR). Therefore, on the claim, you should:

- report 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the FBR.

- report an appropriate E/M based on location or level documented for the E/M service (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...).

- append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M service code to show that the service was separate from the FBR.

- link 881.00 (Open wound of elbow, forearm and wrist; without mention of complication; forearm) and E920.8 (Accidents caused by other specified cutting and piercing instruments or objects) to 10120 and your E/M code to prove medical necessity for the encounters.

Learn more: For complete information on foreign body removal coding, see -When Is Foreign Body Removal Not Foreign Body Removal? The Answer You Need Is Here- contained within this issue.