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Family Practice Coding Alert

Reader Question:

Wound Exploration

Question: What code for superficial wound exploration do I use in the following situation: Patient was seen in the office for a laceration in the foot (1.25-cm deep). The physician made a 0.12-cm incision, looking for a foreign body, but did not find anything embedded.

Wyoming Subscriber

Answer: Because the physician had to make an exploratory incision, code 10120* (incision and removal of foreign body, subcutaneous tissues; simple) or 10121 ( complicated), depending on the circumstances. Code 10120* is used if a simple incision was made in the skin overlying the foreign body, while 10121 is assigned if dissection of underlying tissues was required.

Because no foreign object was removed in the example given, some coders recommend appending modifier -52 (reduced services).

In another instance, the physician may find a foreign object and simply remove it with hemostats or forceps (i.e., removing a splinter). This is included in whatever evaluation and management code is assigned for the visit.