SYLVIA Posted Tue 16th of July, 2019 12:14:26 PM
How would you code the removal of a splinter/bone chip from the mandibular body by using a sonopet to debride ?
SuperCoder Answered Wed 17th of July, 2019 08:48:59 AM
Thanks for your question.
A splinter is a thin piece of material (like wood, glass, or metal) that gets embedded just below the top layer of your skin. Bone chip refer to small pieces of cancellous bone generally used to fill bony defects and to promote reossification.
Removal of splinter suggest code 10120 (Incision and removal of foreign body, subcutaneous tissues; simple). But this seems to be a simple procedure. Code 21025 (Excision of bone (eg, for osteomyelitis or bone abscess); mandible) appears to be nearest to the limited documentation we have.
Please go through with the complete documentation and use the code as suggested.
Hope this helps.
SYLVIA Posted Thu 18th of July, 2019 07:33:27 AM
Here is the complete documentation. Procedure: Her MMF wires were removed. There was a splinter of left mandibular body lingual cortex erupted through mucosa and the adjacent tongue mucosa with a shallow ulcer, likely due to irritation from this splinter. A sonopet was used to ultrasonically debride this bone chip to a smooth surface. The mucosal edges were closed over the bone without tension. Occlusion was reestablished and the MMF wires were replaced. A small area of mucosal dehisence over the left labial mandibular alveolar gingiva was closed with absorbable suture. This concluded the case. Findings: Splinter of left mandibular body lingual cortex erupted through mucosa.
SuperCoder Answered Fri 19th of July, 2019 09:34:18 AM
Since, there is no specific code for the procedure performed above please use unlisted code 21499.
As stated above since the splinter removal code 10120 appears to be a simple procedure and as per the documentation provided the provider did additional work therefore unlisted code will be used.
The mandibular procedure are placed in head section therefore code 21499 can be used.
Kindly, add the documentation when billing the unlisted code.
Hope this helps.
SYLVIA Posted Fri 19th of July, 2019 10:18:18 AM
Thank you for all your help, truly appreciate it.
SuperCoder Answered Mon 22nd of July, 2019 01:55:07 AM
Thank you, happy to help.