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Foreign body removal ?

  1. Default Foreign body removal ?
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    Our doctor attempted a removal of a foreign body of left foot but actually didn't find any foreign body, so what procedure code would I use then? I'm thinking 20103?


    DX: Foreign body left foot

    Procedure: Attempted removal of foreign body of left foot with thorough wound exploration.

    Patient states that he believes he stepped on a piece of glass, six weeks ago.
    Attention was then directed to the plantar aspect of the patient's left foot, where an approx. 2cm curvilinear incision was made in the sulcus between the first and second digits . The incision was deepeened through the subcutaneous tissues and all aspects of the incision site were thoroughly explored, but at no time with a foreign body identified. After full exploration for approximately one hour and 15 minutes in duration, the wound was flushed with copious amounts of normal sterile saline, and the incision site was reapproximated using 4-0 nylon in a simple interrupted technique.

    thanks

  2. #2
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    Quote Originally Posted by BFAITHFUL View Post
    Our doctor attempted a removal of a foreign body of left foot but actually didn't find any foreign body, so what procedure code would I use then? I'm thinking 20103?


    DX: Foreign body left foot

    Procedure: Attempted removal of foreign body of left foot with thorough wound exploration.

    Patient states that he believes he stepped on a piece of glass, six weeks ago.
    Attention was then directed to the plantar aspect of the patient's left foot, where an approx. 2cm curvilinear incision was made in the sulcus between the first and second digits . The incision was deepeened through the subcutaneous tissues and all aspects of the incision site were thoroughly explored, but at no time with a foreign body identified. After full exploration for approximately one hour and 15 minutes in duration, the wound was flushed with copious amounts of normal sterile saline, and the incision site was reapproximated using 4-0 nylon in a simple interrupted technique.

    thanks
    Since there was not foreign body to remove I would use modifier -52

    CPT 20103 guidelines state, "These codes describe surgical exploration and enlargement of the wound, extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or coagulation of minor subcutaneous and/or muscular blood vessel(s), of the subcutaneous tissue, muscle fascia, and/or muscle, not requiring thoracotomy or laparotomy."

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