Orthopedic Coding Alert

Question: If the surgeon performs a foreign body removal (FBR) with forceps alone during an office visit, can we report 10120?

Minnesota Subscriber

Answer: No. You should select a code from the 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …) evaluation and management (E/M) code set for this encounter.

Explanation: A surgical incision to perform the FBR is a must in order to report 10120 (Incision and removal of foreign body, subcutaneous tissues; simple). If you see no indication of an incision in the notes, leave 10120 off the claim.

In the case of 10120, the actual foreign body is secondary to the incision concern. The foreign body could be anything — a thorn, a splinter, or something left medically like an embedded staple or stitch — but your surgeon has to make a cut to make the 10120 cut. Also, remember that if the FBR is “complicated,” you might be able to report 10121 (Incision and removal of foreign body, subcutaneous tissues; complicated).

Some of the characteristics of a complicated FBR could involve:

• Infection;
• Scarring in the area;
• Multiple foreign bodies;
• Delayed treatment;
• Extensive cleaning.

Payers might vary as to their definition of a complicated repair, so check with a provider and/or payer if you’re wondering what might constitute a 10121 treatment.