2025 CPT code 20102
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Musculoskeletal System - Wound Exploration Surgery Feed
Exploration of a penetrating wound (separate procedure) in the abdomen, flank, or back.
Modifiers may be applicable depending on the specific circumstances of the procedure.For example, modifier 52 (reduced services) may be used if the exploration is less extensive than expected, or modifier 76 (repeat procedure) if the exploration is repeated by the same physician.
Medical necessity is established by the presence of a penetrating wound requiring exploration to assess the extent of injury, identify foreign bodies, control bleeding, and ensure appropriate wound management. The decision to explore is based on clinical judgment.
The clinical responsibility lies with the surgeon performing the exploration. This includes assessing the extent of injury, removing foreign bodies, controlling bleeding, and performing basic wound repair.More extensive repairs or procedures would require additional codes.
In simple words: The doctor examines the inside of a penetrating wound in the abdomen, side, or back to check for damage and remove any foreign objects like bullet fragments or a knife tip.This might involve cleaning the wound, removing damaged tissue, and closing it.
This CPT code, 20102, describes the surgical exploration and enlargement of a penetrating wound located in the abdomen, flank, or back.The procedure includes extension of dissection to determine the penetration depth, debridement of damaged tissue, removal of foreign bodies, ligation or coagulation of minor subcutaneous and/or muscular blood vessels, and repair of subcutaneous tissue, muscle fascia, and/or muscle.It does not include thoracotomy or laparotomy; those procedures would be coded separately if performed.Simple, intermediate, or complex repair of wounds not requiring exploration and enlargement should be coded using Integumentary System repair codes.
Example 1: A patient presents with a gunshot wound to the abdomen.The surgeon performs an exploration of the wound, removing bullet fragments and performing debridement of damaged tissue.20102 is used to report the wound exploration., A patient sustains a stab wound to the flank. The surgeon explores the wound, identifying and removing a piece of clothing embedded in the tissue.20102 is used., A patient presents with a penetrating abdominal wound following a motor vehicle accident. The surgeon explores the wound, finding minor damage to muscle and subcutaneous tissue.No major vessels or organs are damaged. 20102 is reported.
Detailed operative report documenting the exploration, including location and size of the wound,description of tissues encountered, foreign bodies removed (if any),details about vascular injury and repair, and description of wound closure. Preoperative and postoperative diagnosis, imaging studies (if any), and any complications should also be documented.
** This code should only be used for penetrating wounds; it is not appropriate for blunt trauma.Always refer to the most current CPT guidelines and coding resources for accurate coding.
- Revenue Code: P6B (Minor Procedures - Musculoskeletal)
- RVU: Information on RVUs, payment rates, and CMS conversion factors varies by payer and location and is not included in this response. Consult your local Medicare Administrative Contractor (MAC) or payer for specific reimbursement information.
- Global Days: The global surgical period information is not specified for this code. This information should be determined according to payer guidelines and local practice standards.
- Payment Status: Active
- Modifier TC rule: A Technical Component (TC) modifier is not typically applicable to this code.
- Fee Schedule: Historical fee schedule data is not included here.Consult your local Medicare Administrative Contractor (MAC) or payer for historical fee schedule information.
- Specialties:General Surgery, Trauma Surgery, Emergency Medicine
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, Emergency Room - Hospital