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2025 CPT code 20103

Surgical exploration of a penetrating wound of the extremity.

This code is for penetrating trauma wounds only, not blunt trauma. If repair of major structures or vessels requiring thoracotomy or laparotomy is performed, those codes supersede 20103. Cast application is not part of preoperative care, so modifier 56 is not applicable.

Modifiers may be applicable. Modifier 54 (Surgical Care Only) may be used if the initial treating physician does not provide subsequent care. Modifier 76 (Repeat Procedure by Same Physician) may be appended if the same physician performs a subsequent re-reduction of a fracture or dislocation.

Medical necessity for 20103 is established by the presence of a penetrating wound requiring exploration to assess the extent of the injury and remove foreign bodies, prevent infection and further damage to underlying structures.

The physician is responsible for assessing the extent of the wound, removing foreign bodies, debriding damaged tissue, controlling bleeding of minor vessels, and exploring the wound to determine the need for further intervention.

IMPORTANT:If a repair is done to major structure(s) or major blood vessel(s) requiring thoracotomy or laparotomy, then those specific code(s) would supersede the use of this code. For simple, intermediate, or complex repair of wounds not requiring enlargement or extension of dissection, use specific Repair codes in the Integumentary System section.

In simple words: The doctor examines the inside of a deep wound in your arm or leg to see how bad it is and take out anything that shouldn't be there, like a bullet or piece of glass. They might clean the wound, remove damaged tissue, and fix any small blood vessels.

Exploration of penetrating wound (separate procedure); extremity. This includes enlargement, debridement, removal of foreign bodies, and ligation or coagulation of minor subcutaneous and/or muscular blood vessels, of the subcutaneous tissue, muscle fascia, and/or muscle, not requiring thoracotomy or laparotomy.

Example 1: A patient presents to the ER with a gunshot wound to the thigh. The physician explores the wound, removes bullet fragments, debrides damaged tissue, and ligates a minor muscular blood vessel. Code 20103 is reported., A patient is brought to the emergency room with a stab wound to the forearm. The physician explores the wound, extends the dissection to assess the depth of penetration, removes a small piece of the knife blade, and repairs minor subcutaneous blood vessels. Code 20103 is reported., A child falls and impales their hand on a rusty nail. The physician explores the wound in the hand, removes the nail, debrides devitalized tissue, and ligates a minor subcutaneous blood vessel. Code 20103 is reported.

Documentation should include the location and size of the wound, the depth of penetration, the presence of any foreign bodies, the extent of debridement, the repair of any minor blood vessels, and the complexity of the exploration.

  • Payment Status: Active
  • Specialties:Emergency Medicine, Trauma Surgery, Orthopedic Surgery, General Surgery, Hand Surgery
  • Place of Service:Emergency Room - Hospital, Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center
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