Purulent drainage/no remaining foreign body found

Charity Evans

Hazelwood, MO
Best answers

I need assistance with CPT code selection for purulent drainage.

The patient got a splinter and removed what could be seen, thought there was still some in there and came in to have remaining splinter removed by provider.

In procedure note, Provider stated "Anesthetized with 0.5 mL 1% lidocaine. Cleansed with rubbing alcohol. Using 27 gauge needle, small opening made to skin. Approximately 0.25 mL purulent drainage expressed. Wound explored, no evidence of remaining foreign body. Cleansed well with hibiclens and water. Bandaid applied."

Under the assessment, the provider documented the patient with a diagnosis of "Foreign body in skin of finger."

Under the plan, the provider documented "I do not see any remaining foreign body. Soak the finger in warm soapy water for 20-30 minutes 2-3 times a day for next few days. Keep covered with bandaid when not soaking. There appears to be a localized infection. Complete full course of antibiotic as prescribed. Let me know if any increasing redness or swelling, especially if extending up your finger toward your hand."

Provider submitted CPT code 10120 for removal of foreign body, simple and used ICD-10-CM dx code S60.459A for Superficial foreign body of unspecified finger, initial encounter.

As there was no foreign body removed, I don't believe that CPT code 10120 is appropriate/supported. Would CPT code 10060 be appropriate instead of 10120 as the wound was drained and there was no foreign body removed?

Also, would ICD-10-CM diagnosis code L089 for Local infection of the skin and subcutaneous tissue, unspecified be appropriate/supported instead of S60.459A, or would you include both dx codes?