Hello coders!
I work for a family physician and I'd like to get advice on a coding issue. A patient came in today c/o foreign body in his forearm. The doctor explored the area but did not find any foreign body. In my opinion, the code that best fits the scenario would be 10120, but can this code be used when a foreign body is susptected, but not found?
The documentation states "he has a small puncture wound of R forearm, it has a firmness under the skin, scabbed area removed and no foreign body seen so this area was sterilized and anesthetized with 2% lidocaine with epi 1ml used. I lanced the surface to below the dermis about 5mm. I explored the area and no foreign object seen. This was closed with butterfly tape and abx cream applied. "
Any advice would be appreciated
I work for a family physician and I'd like to get advice on a coding issue. A patient came in today c/o foreign body in his forearm. The doctor explored the area but did not find any foreign body. In my opinion, the code that best fits the scenario would be 10120, but can this code be used when a foreign body is susptected, but not found?
The documentation states "he has a small puncture wound of R forearm, it has a firmness under the skin, scabbed area removed and no foreign body seen so this area was sterilized and anesthetized with 2% lidocaine with epi 1ml used. I lanced the surface to below the dermis about 5mm. I explored the area and no foreign object seen. This was closed with butterfly tape and abx cream applied. "
Any advice would be appreciated