2025 CPT code 10121
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Incision and Drainage Procedures Integumentary System Feed
Incision and removal of a foreign body from subcutaneous tissue; complicated.
Modifiers 22, 51, 52, 59, 76, 77, 78, 79, and others may be applicable depending on the specific circumstances of the procedure.
Medical necessity is established by the presence of a foreign body in the subcutaneous tissue that requires removal to prevent infection, reduce pain, or restore function.The complexity of the procedure must be documented to support the use of CPT 10121 versus the simpler CPT 10120.
The physician or qualified healthcare professional is responsible for prepping and anesthetizing the patient, incising the skin to expose the foreign body, performing any necessary exploration (potentially with imaging guidance), controlling bleeding, irrigating the wound, closing the incision (in layers if necessary), cleaning, and dressing the wound.
In simple words: This code covers removing a foreign object (like a splinter or piece of glass) from under your skin. It's used when the removal is difficult because the object is hard to find or the wound needs extra care to close.
This CPT code describes the surgical removal of a foreign body embedded in the subcutaneous tissue.The procedure is considered "complicated" due to factors such as extensive dissection required to locate and remove the foreign body, the need for imaging guidance (e.g., X-ray, ultrasound), or layered closure of the wound.The procedure includes incision, exploration, removal of the foreign body, hemostasis (control of bleeding), wound irrigation, and closure (which may involve multiple layers depending on the depth of the incision). The wound is then cleaned and dressed.
Example 1: A 10-year-old boy presents with a deeply embedded wood splinter in his forearm.The splinter is difficult to locate, requiring extensive probing and local anesthesia.The physician uses forceps to remove the splinter and closes the wound with sutures in multiple layers., A 30-year-old woman presents with a small piece of glass lodged deep in her fingertip. The physician uses an X-ray to precisely locate the glass fragment before making a small incision to remove it. The wound is cleaned and closed with a single stitch., A 65-year-old man presents with a large piece of metal deeply embedded in his thigh after a workplace accident. The physician uses imaging to assess the extent of the injury, makes a larger incision to remove the metal, and controls significant bleeding before performing layered closure.
Detailed operative report including the type and location of the foreign body, the size and depth of the incision, the techniques used for removal, the extent of exploration, the need for imaging guidance, the method of hemostasis, the details of wound closure (including layers if applicable), and any complications encountered.Preoperative and postoperative diagnoses should also be documented.
** The distinction between CPT 10120 (simple) and 10121 (complicated) is based on the complexity of the procedure.Factors such as extensive exploration, imaging guidance, or layered closure should be documented to justify the use of 10121.Local anesthesia is often used, but general anesthesia might be indicated in more complex cases.Always consult current CPT guidelines and payer-specific policies.
- Revenue Code: P6A (Minor Procedures - Skin)
- RVU: 8 RVUs (office setting)
- Global Days: 10-day global period
- Payment Status: Active
- Modifier TC rule: TC modifier is not applicable to this code.
- Fee Schedule: Consult payer-specific fee schedules and historical data for reimbursement rates.Note that RVUs vary based on location and other factors.
- Specialties:General Surgery, Plastic Surgery, Emergency Medicine, Family Medicine
- Place of Service:Office, Hospital Outpatient, Ambulatory Surgical Center, Urgent Care Facility, Emergency Room - Hospital