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Official Description

Incision and removal of foreign body, subcutaneous tissues; complicated

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 10121 involves the incision and removal of a foreign body that is embedded within the subcutaneous tissues, indicating a more complex situation than a simple removal. This procedure is necessary when a foreign object, such as a splinter, glass shard, or other material, has penetrated beneath the skin and is not easily accessible. The term 'complicated' refers to instances where the foreign body is deeply embedded, making it challenging to locate and extract. During the procedure, a straight or elliptical incision is made in the skin to access the affected area. The surgeon then carefully separates the skin layers to identify the foreign body. Once located, specialized instruments such as a hemostat or grasping forceps are utilized to grasp and remove the foreign object. Depending on the extent of the incision and the condition of the surrounding tissues, the incision may either be closed with sutures or left open to heal naturally through secondary intention. This procedure is distinct from simpler cases, which are coded under CPT® Code 10120, highlighting the increased complexity and skill required for the successful removal of deeply embedded foreign bodies.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 10121 is indicated in specific scenarios where a foreign body is embedded in the subcutaneous tissues and requires surgical intervention for removal. The following conditions may warrant this procedure:

  • Deeply Embedded Foreign Body The presence of a foreign object that is not easily accessible due to its depth beneath the skin surface.
  • Difficulty in Localization Situations where the foreign body is challenging to locate, necessitating a more extensive surgical approach.
  • Complicated Removal Cases where the foreign body is surrounded by or adheres to underlying tissues, requiring dissection for successful extraction.

2. Procedure

The procedure for CPT® Code 10121 involves several critical steps to ensure the safe and effective removal of the foreign body. Each step is essential for achieving the desired outcome while minimizing complications.

  • Step 1: Incision The first step involves making a straight or elliptical incision over the area where the foreign body is suspected to be located. This incision is carefully planned to provide optimal access to the embedded object while considering the surrounding anatomical structures.
  • Step 2: Separation of Skin Layers After the incision is made, the surgeon gently separates the skin layers to expose the subcutaneous tissues. This step is crucial for visualizing the foreign body and assessing the extent of tissue involvement.
  • Step 3: Identification of the Foreign Body Once the tissues are separated, the surgeon identifies the foreign body. This may require careful exploration of the area to ensure that the object is located accurately.
  • Step 4: Removal of the Foreign Body Using a hemostat or grasping forceps, the surgeon then grasps the foreign body and removes it from the subcutaneous tissues. This step may involve additional dissection if the foreign body is adherent to surrounding tissues.
  • Step 5: Closure of the Incision After the foreign body is successfully removed, the surgeon decides whether to close the incision with sutures or leave it open to heal by secondary intention. The choice of closure method depends on the size of the incision and the condition of the surrounding tissues.

3. Post-Procedure

Post-procedure care for CPT® Code 10121 includes monitoring the incision site for signs of infection, proper wound care, and instructions for the patient regarding activity restrictions. If the incision is closed, the patient may need follow-up visits for suture removal. If left open, the healing process will be monitored to ensure proper closure by secondary intention. Patients should be advised to keep the area clean and dry, and to report any unusual symptoms such as increased pain, redness, or discharge from the incision site.

Short Descr INC&RMVL FB SUBQ TISS COMP
Medium Descr INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMP
Long Descr Incision and removal of foreign body, subcutaneous tissues; complicated
Status Code Active Code
Global Days 010 - Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Hospital Part B services paid through a comprehensive APC
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6A - Minor procedures - skin
MUE 2
CCS Clinical Classification 174 - Other non-OR therapeutic procedures on skin and breast
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
LT Left side (used to identify procedures performed on the left side of the body)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
RT Right side (used to identify procedures performed on the right side of the body)
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
74 Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CG Policy criteria applied
CR Catastrophe/disaster related
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
FA Left hand, thumb
GA Waiver of liability statement issued as required by payer policy, individual case
GC This service has been performed in part by a resident under the direction of a teaching physician
GW Service not related to the hospice patient's terminal condition
KX Requirements specified in the medical policy have been met
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
SG Ambulatory surgical center (asc) facility service
T1 Left foot, second digit
T2 Left foot, third digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
TA Left foot, great toe
TR School-based individualized education program (iep) services provided outside the public school district responsible for the student
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2024-01-01 Changed Short and Medium Descriptions changed.
2013-01-01 Changed Medium Descriptor changed.
Pre-1990 Added Code added.
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