You Be the Coder: Look within before assigning a penetrating trauma code

Question: A patient presents to the emergency department after he cut the tip of his finger off while removing the grass catching attachment from his lawnmower. In addition to the E/M documentation, the chart notes read as follows: "13:51 Hemostasis: Moderate amount of left phalanx of 3rd and 4th digits. Controlled using cauterization of both digital arteries of 4th digit, gel foam. Bleeding stopped." Can I report code 20103 for this service?

Alabama Subscriber

Answer: Code 20103 (Exploration of penetrating wound [separate procedure]; extremity) is located in the Wound Exploration --" trauma (e.g. Penetrating gunshot, Stab Wound) section of CPT®. The injury [...]

- Published on 2011-08-23