Wiki Help coding foreign body removal

[dsibley67]

Can someone please review the op note and provide me with some guidance on the correct coding? I was thinking that this is a simple foreign body removal (10120), the physician is thinking (10121). Thanks in advance!

The patient was seen preoperatively, site was marked and
verified. A time-out was taken at the beginning of the procedure. A 1-inch incision was made along the
ulnar aspect of the right hand at the base of the small finger metacarpal, carefully dissected down,
identified a encapsulated piece of glass fairly superficial to the muscle belly. The glass was approximately
1 cm in size and removed without incident. The wound was then irrigated. We continue to explore the
wound and were unable to identify any further foreign objects. The wound was then closed with 4-0
Prolene. Bupivacaine/Ketorolac was used for local anesthesia. Soft dressing was applied and tolerated
the procedure well.

 

[NRaizman]

This is 10120. It corresponds almost exactly to the Vignette for the case, and that is also supported by CPT-A.

You should tell your surgeon - if he or she wants to bill a complex code, then he or she has to describe a complex operation. No one in the world will look at this operative dictation and say, "well, this seemed complicated." They will say, "this is a glorified removal of a splinter." Both 10120 and 10121 describe making an incision and dissecting down to remove the foreign body. Complicated vs simple is poorly defined but the differential work is supported by describing depth, incarceration, extensive dissection through scar or inflammatory tissue, fragmentation, navigating around vital structures, or multiple FB's. None of that is described. If your surgeon thought this was complicated then he or she shot herself in the foot by describing a simple and easy procedure.

 

[dsibley67]

This is 10120. It corresponds almost exactly to the Vignette for the case, and that is also supported by CPT-A.

You should tell your surgeon - if he or she wants to bill a complex code, then he or she has to describe a complex operation. No one in the world will look at this operative dictation and say, "well, this seemed complicated." They will say, "this is a glorified removal of a splinter." Both 10120 and 10121 describe making an incision and dissecting down to remove the foreign body. Complicated vs simple is poorly defined but the differential work is supported by describing depth, incarceration, extensive dissection through scar or inflammatory tissue, fragmentation, navigating around vital structures, or multiple FB's. None of that is described. If your surgeon thought this was complicated then he or she shot herself in the foot by describing a simple and easy procedure.

My thoughts exactly!! Thank you for confirming what I was thinking also.