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Internal Medicine Coding Alert

You Be the Coder:

Exploration But Foreign Body Not Found? Here's What You Should Do

Question: Our internist recently saw a patient who came in complaining of some discomfort in his finger. The patient said that he was working with wood and felt that a splinter of wood had entered the wrist. The physician explored the wound after making a small incision under local anesthesia but he was not able to find anything. The patient returned the next day with the same complaint. Our physician repeated the procedure through another incision made next to the previous one. Further exploration revealed no foreign body and again sutures were placed to close the incision. Can I report a foreign body removal code even though no foreign body was found in the site?

Dallas Subscriber

Answer: Since no foreign body was found at the site, you will be wrong if you report the procedure with a foreign body removal code such as 25248 (Exploration with removal of deep foreign body, forearm or wrist). However, as the descriptor to 25248 includes the term “exploration,” you can consider reporting this code with the modifier 52 (Reduced services) attached to it. You should attach documentation with the claim saying that your clinician performed the exploration for finding a foreign body but could not find anything.

However, if the payer does not allow the use of this code with the modifier appended, you should try reporting only a low level E/M service code such as 99201 (if patient is new) or 99212 (for an established patient) for the first visit. For the second visit, neither the E/M nor the procedure can be coded since there was no separately billable E/M service and no foreign body was found.