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Coding Wound Exploration

  1. Default Coding Wound Exploration
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    40 yr old male,helping build fence on farm, when a piece of barbwire dislodged & went into forearm. ER xray showed a metal fragment. ER phys made an incision & tried to remove, but failed. Closure with 1 stitch & referral to Ortho surgeon next day. Would procedure code 20103 be appropriate?

  2. #2
    Milwaukee WI
    Default 20103
    Here's the lay description for CPT 20103:
    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.

    If your ER physician's documentation matches this description, then that's your code. This code WILL accept a -52 modifier if reduced service was performed.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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