Wiki Complex Foreign Body Removal

[joglesbee]

We had a doctor in our office, workers comp setting, perform exploratory surgery on a hand to remove a foreign body from a patients hand. The surgery was done only after xray showed no clear signs of a foreign body in the hand. Patient continued to state there was a foreign body and he decided to perform the exploratory surgery. After making a 1cm incision he felt for the foreign body, finally locating it he was able to successfully remove a piece of wood 3cm long x 1cm in width. Wound was closed with 1 suture, simple.

How should this be coded? I have the xray hand series and the E/M figured out, just needing to know how to code the surgery.

 

[joglesbee]

found it myself 20103

 

[FTessaBartels]

I don't think so

This is from Encoder Pro
20103 - Exploration of penetrating wound (separate procedure); extremity
The physician explores a penetrating wound in the operating room, such as a gunshot or stab wound, to help identify damaged structures. Nerve, organ, and blood vessel integrity is assessed. The wound may be enlarged to help assess the damage. Debridement, removal of foreign bodies, and ligation or coagulation of minor blood vessels in the subcutaneous tissues, fascia, and muscle are also included in this range of codes. Damaged tissues are debrided and repaired when possible. The wound is closed (if clean) or packed open if contaminated by the penetrating body. Report 20100 for exploration of a neck wound. Report 20101 for exploration of a chest wound. Report 20102 for exploration of an abdomen, flank, or back wound. Report 20103 for exploration of a wound to an extremity.

I do NOT think this is what your physician performed in the office ...

I think what you want is
20520 - Removal of foreign body in muscle or tendon sheath; simple
The physician removes a foreign body in a muscle or tendon sheath. The physician incises the skin and dissects to the muscle or sheath. The foreign body is isolated by palpation or radiographic imagery (separately reported) and removed. The incision may be closed if clean or packed if contaminated by the object. Report 20520 if the removal is simple; report 20525 if the foreign object lies deep or requires a complicated procedure to remove it.

I do not suggest 20525 because the "wound" was closed with a single simple suture. Of course, reading the entire procedure note might result in a different code.

Hope that helps.

F Tessa Bartels, CPC, CEMC