ED Coding and Reimbursement Alert

If you think FBR codes are all about anatomic site, you're bound to miss the reimbursement mark - wound depth can be crucial to choosing the correct code.

Coding for foreign-body removal (FBR) can vary greatly depending on the type of foreign body, its anatomic location, and the depth from which the physician must remove it. Compare your toughest FBR claim to these scenarios to find the right coding solution.

Example #1: No Incision Means No Separate FBR

The situation: While operating a metal lathe, the patient embeds several small metal filings in his shoulder. In the emergency department (ED), the physician inspects the wounds and, using tweezers, extracts the shards. 

The solution: Because the ED physician did not create a separate incision to remove the foreign bodies, you cannot code an FBR, says Tara L. Conklin, CPC, an instructor for CRN Institute, a coding and reimbursement institution offering courses in reimbursement, medical billing, outpatient coding certification, and inpatient coding certification. Rather, you should include the removal of the metal filings as a component of whatever evaluation and management service (99281-99285) the physician documents.
 
The "what if?" scenario: The patient received deep wounds when he was hit from flying debris from an exploding propane tank. The physician explores the open wound, which requires enlarging the wounds and significant dissection. Following exploration, he removes several pieces of debris, and debrides and closes the wounds.

In this case, the doctor performed wound exploration (20100-20103) with removal of the foreign body, which you should report using the wound exploration code that best describes the anatomic location of the wound the physician explored (such as 20101, Exploration of penetrating wound [separate procedure]; chest). Removal of foreign bodies and wound closure is included in wound exploration codes.

Keep in mind that the relative value units (RVUs) for these codes are rather high and are not intended to reflect uncomplicated FBR with a laceration repair.

Example #2: For Musculoskeletal FBR, Code by Location and Depth

The situation: The patient in case study #1 removes the metal filings himself. After several weeks, his wounds heal, but one metal filing remains and has now become imbedded beneath the skin and into muscle. The ED physician sees the patient and, through an incision, removes the foreign body from the patient's shoulder. 

The solution: When reporting FBR from a musculoskeletal site (muscle or even bone), you must select the correct FBR code by anatomic location and depth, Conklin says. 

The musculoskeletal portion of CPT (20000-29999) includes specific FBR codes for the shoulder, humerus (upper arm) and elbow, hip, femur (thigh region) and knee joint, and feet and toes. CPT further defines these codes according to depth (such as subcutaneous, deep or, in some cases, complicated).

For example, for FBR in the shoulder, you must select among codes 23330 (Removal of foreign body, shoulder; subcutaneous), 23331 (... deep [e.g., Neer hemiarthroplasty removal]) and 23332 (... complicated [e.g., total shoulder]). If the physician removes the foreign body from the subcutaneous tissue or anywhere else above the fascia, you would select 23330. If he must go below the fascia, use 23331.

In the case of a particularly complex procedure (such as when the whole shoulder area is involved), you should select 23332, although this level of complexity generally requires a trip to the operating room, Conklin says.

In case #2, your best code selection is 23331.

The "what if?" scenario: What if the physician must remove a foreign body from an area that does not have a specific set of CPT codes such as the head, neck, forearm, flank, wrist or fingers?

"In this case, the depth of the FBR determines the code choice," says Michael Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems in Stoneham, Mass.

You'll choose from these codes from the integumentary and musculoskeletal sections, Granovsky says: