tci ED Coding & Reimbursement Alert - 2001 Issue 5

Complicated Versus Simple Foreign Body Removal: Know the Difference Between 10120* and 10121

Because CPT does not offer specific guidelines to distinguish simple from complicated foreign body removal, ED coders may have difficulty choosing between 10120* (incision and removal of foreign body, subcutaneous tissues; simple) and 10121 (... complicated). Supporting the Codes The physicians documentation is most important when determining the level of the removal, and must support the coding during an audit. The coding relies on [the physicians] medical decision-making. I dont feel qualified, nor do I think any other nonclinician should feel qualified, to determine that. If [the documentation] doesnt specify complicated, I wouldnt assume that it was, says Charlene...

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