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 codè 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 codè if the surgical report doesn’t provide any more documentation.

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

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.

2. Search Musculoskeletal Codè for Specific Site

CPT® contains higher-paying FBR codè s than 10120-10121, but the surgeon needs to document the following two details before you can use the codès:

Location: You’ll find myriad FBR codès scattered throughout CPT®’s “Musculoskeletal System” section (20000-29999),...