Question: A new patient reported with a splinter of wood in her forearm, and the physician removed the splinter with tweezers. Physician notes indicate a level-two evaluation and management service. Is this a foreign-body removal (FBR)?
Ohio Subscriber
Answer: In your scenario, it appears unlikely that a definitive FBR took place. According to CPT, the physician must make an incision for the procedure to qualify as an FBR. If there is no incision, you should just report the proper E/M.
On your claim, you should report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making) for the service.
(Depending on the location of the injury, the nature of the foreign body, etc., this E/M service might climb higher than 99202 in some cases.)
Exception: If, however, the physician’s notes indicate that the splinter was embedded in the patient’s forearm and he had to perform an incision to excise it, you could report:
• 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for simple removals or
• 10121 (… complicated) for complicated removals.
