Patient came into office for a pre-op to surgery. She had dermal piercings on one cheek, and one on each shoulder.
ICD-9: 729.6 (residual foreign body in soft tissue) 873.41 (open wound cheek; without complication) 880.00 (open wound shoulder region; without complication) V90.12 (retained non-magnetic metal fragments)
CPT code: 10121 ( incision and removal of foreign body; complicated)
I would use code 10121 three times. One for the cheek linked to 729.6, 873.41, V90.12 then one per each shoulder linked to 729.6, 880.00, V90.12 with RT and LT modifiers and also with a -59 modifier on the last two codes because they are a different site or incision.
The reason I have the open wounds in there is because the dermals essentially are open wounds. They are posts that go under the skin and butterfly out. This leaves the hole open and susceptible to bacteria and infection. I feel using these diagnosis codes along with foreign body in soft tissue tells a better story. After all we must paint a clear picture with vivid detail if we want to get paid.
Donâ€™t forget to put a -25 modifier on the office visit.
Also, since this was performed during a pre-op visit, and there is a global period, I will need to make sure I modify the surgery she is having today with a -79 (unrelated procedure during the post-operative period.
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