Part B Coding Coach: 10120 or Beyond: Site, Depth, Complexity Drive Code Choice

Follow 3 pointers to snag maximum pay.

From just under the skin to deep within the bowels, your general surgeon might perform a foreign body removal (FBR) that calls on a wide range of coding know-how. Zero in on the right code every time by implementing these four principles:

1. Use 10120-10121 for Any Site Under Skin

If your surgeon makes an opening to remove any foreign body, such as a glass shard or a metal filing, but doesn't indicate an anatomic site or depth in the op report, you'll probably choose 10120 (Incision and removal of foreign body, subcutaneous tissues; simple). You can't choose a more specific code if the surgical report doesn't provide any more documentation.

Caveat: Because the code requires incision, look for a sharp object when considering 10120. If the documentation doesn't include this detail, use an E/M service code (such as 99201-99215, Office or Other Outpatient Services) instead of the skin FBR code.

Look for complications: If the surgeon uses the term "simple" in the op note or fails to note any extenuating circumstances, you're good to go with 10120. But the surgeon might perform a complicated FBR, meaning that the foreign body was harder than usual to remove. In these situations, the note should indicate, for example, extended exploration around the wound site, presence of a complicating infection, or sometimes the need to use visualization and localization techniques, such as x-ray. In those cases, you should choose 10121 (… complicated) for a subcutaneous FBR with no mention of anatomic site.

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2. Search Musculoskeletal Codes for Specific Site

CPT codes contain higher-paying FBR codes than 10120- 10121, but the surgeon needs to document the following two details before you can use the codes:

Location: You'll find myriad FBR codes scattered throughout CPT's "Musculoskeletal System" section (20000-29999), but you can't use any of them if the surgeon doesn't document the removal's anatomic site.

Depth: In addition to anatomic site, the musculoskeletal codes distinguish FBR based on the depth of the foreign body. When coding or auditing, look in the notes for the term "fascia," suggests Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas. CPT provides two FBR codes for many anatomic sites: one for subcutaneous (above the fascia) removal, and one for "deep" (below the fascia) removal.