Dermatology Coding Alert

Here’s what separates an E/M service from an FBR.

When your dermatologist performs foreign body removal (FBR) for a patient, you’ll have to decide whether the service meets the definition of “FBR” for coding purposes.

You’ll code services that qualify for FBR with 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (… complicated), depending on other encounter specifics. If the service doesn’t meet FBR coding criteria, however, you’ll have to choose another coding route.

Take a look at this advice to send you down the proper coding road each time you navigate an FBR claim.

Consider Location, not Object, on FBs

When you are looking for proof of FBR, check the documentation to see where, not necessarily what, the provider removed during the service.

A codeable FBR service involves “a foreign body in the subcutaneous tissue, just below the dermis,” explains Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC,  internal audit manager with PeaceHealth in Vancouver, Wash.

The FB could be just about anything: “a thorn, a splinter, or something left medically like an embedded staple or stitch … that was intended to be left in place but is moving out of the body and is now in the subcutaneous tissue,” Bucknam continues.

Best bet: Focus on how deep the FB is embedded in the dermis when deciding whether to report an FBR code.

Spot Incision Evidence to Cinch FBR Code

Once you decide if the embedded object is a subcutaneous FB, check the notes for evidence of an incision. “If the physician can just take a forceps and grasp the foreign body and pull it out, then there is no separate coding for the [FBR] service,” says Bucknam.

Typically, the physician will devote a certain amount of time/tools trying to remove the FB without an incision, explains Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, of ACE Med Group in Pittsburgh, Pa.

“The physician should set a … time limit or an implement limit. After using certain tools without success or after trying for a period of time,” the physician might opt for an incision, Hauptman continues. Be sure to include a description of the provider’s efforts to remove the FB without an incision, which includes the time spent and tools used during the service, on any claim that includes 10120 or 10121.

Example: A patient reports to the dermatologist with a splinter on the bottom of her right foot. The dermatologist spends 11 minutes trying to remove the splinter with tweezers, but cannot grasp the tip of it. The dermatologist then uses a scalpel to make a small incision in the patient’s foot and removes the FBR with tweezers. On this claim, report 10120 for the FBR.

Plan B: Without proof of the incision, you’ll have to report the appropriate office evaluation and management (E/M) code for the service (99201 [Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making…] through 99215 [Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity…]).

Location, Infection Could Complicate FBR

According to Bucknam, complicated FBRs are rare. When you do see them, however, the complication might arise from:

• infection,
• previous scarring in the area,
• multiple foreign bodies, or
• delayed treatment.

You can often determine the complexity of an FBR based on other factors as well. Often, complexity depends on “what the foreign body is, where it is, or how big it is,” Hauptman explains.

Other complicating factors that could lead to a 10121 FBR include:

• an FB lodged in such a way that it makes removal complicated,
• an FB that is close to a major organ or artery, or
• an FB that is wedged under a bone.

“There are many factors that could play into the FB removal being more difficult,” Hauptman explains. If you are unsure about the complexity of an FBR, check with your dermatologist to determine the proper code for the encounter.