ED Coding and Reimbursement Alert

Eye, soft-tissue FBRs have different code sets

With those carefree summer days fast approaching, careful ED coders should be brushing up on the basics of foreign-body removal (FBR) coding. As sure as firecrackers on Independence Day, more patients show up to the ED for FBRs in the summer months.

There are several code groups to represent FBRs, depending on the situation. Your FBR code choice will hinge on where the FB is located and what steps your physician takes to remove it. Check out this expert review of some of the more common FBR scenarios in the ED.

Corneal FBR May Require Slit Lamp

When a patient presents to the ED with a foreign body in his eye, you should first decide whether the FB was conjunctival or corneal, says Peggy Gunning, CPC, coding manager at TERM Billing Inc. in Mansfield, Texas.

For conjunctival foreign bodies, coders should report one of the following codes, depending on the location and penetration of the wound:

- 65205 (Removal of foreign body, external eye; conjunctival superficial). This type of FBR -may include removal of a superficial FB utilizing the beveled edge of a needle, a cotton tip applicator, forceps, tweezers or a spud,- Gunning says.

- 65210 (Removal of foreign body, external eye; conjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating). This code refers to the procedure to remove an -embedded FB,- which is more complicated and may even require an incision. While the incision may penetrate the conjunctiva, it does not penetrate the sclera, Gunning says.

When the patient presents with a corneal FB, your coding choices change. Coders should choose from these codes for corneal FBRs, depending on whether the physician used a slit lamp:

- 65220--... corneal, without slit lamp

- 65222--... corneal, with slit lamp.

The ED physician typically uses a slit lamp if the FB is in the cornea. Often an eye FB -isn't readily visible to the examiner. By using the slit lamp, the doctor can be more certain that a microscopic FB hasn't been over-looked,- says Linda Martien, CPC, CPC-H, coding specialist at National Healing Inc. in Boca Raton, Fla. The physician may or may not incise the corneal tissue during a slit lamp FBR.

Example: A mechanic reports to the ED complaining of eye pain after doing some auto bodywork. After documenting a level-three ED E/M service, the physician examines the eye with a slit lamp, which reveals a small metallic foreign body in the cornea. The physician removes the foreign body, writes a prescription and arranges appropriate follow-up care.

On the claim, you should:

- report 65222 (Removal of foreign body; corneal, with slit lamp) for the FBR.

- append 930.0 (Corneal foreign body) to 65222 to represent the FB.

- report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; moderate-complexity medical decision-making) for the E/M service.

- append ICD-9 code 379.91 (Pain in or around eye) to 99283 to represent the patient's eye pain.

- attach modifier 25 (Significant, separately identifiable evaluation and management service ...) to 99283 to show that the E/M and FBR were separate services.


Soft-Tissue FBR Must Meet CPT's Definition

When the physician removes a soft-tissue FB, coders must be sure the procedure meets CPT's definition of FBR before reporting an FBR code, Gunning says.

Depending on the FB's location, the physician may have to make an incision during the FBR in order to report a soft-tissue FBR code. When the code requires an incision but the physician does not make an incision while removing the FB, then you should just report the appropriate-level evaluation and management code, Gunning says.

Consider these two scenarios:

Example: A small child with a tick embedded in her scalp is brought to the ED by concerned parents. The physician examines the area around the tick, then removes it with a pair of tweezers. Notes indicate a level-two evaluation and management service. In this scenario, the physician removed the FB without making an incision.

On the claim, report 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) for the service.

Don't forget to attach ICD-9 code 910.6 (Superficial injury of face, neck and scalp except eye; superficial foreign body [splinter] without major open wound and without mention of infection) to 99282 to prove the encounter's medical necessity.

Example: A patient with a wood splinter in his forearm reports to the ED. The splinter is lodged under his skin, and the end of the splinter is not wholly visible at the wound site. The ED physician tries to grab the end of the splinter with a pair of tweezers, to no avail. Using a scalpel, she makes a tiny cut over the spot where the edge of the splinter is lodged and then uses tweezers to pull the splinter out.

In this instance, the physician had to make an incision, so you can report an FBR code. On the claim, report 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the procedure.

Don't forget to attach ICD-9 code 913.6 (Superficial injury of elbow, forearm, and wrist; superficial foreign body [splinter] without major open wound and without mention of infection) to 10120 to prove medical necessity for the encounter.

(Note: Separate rules, and codes, apply to foot FBRs, where no incision is required in order to bill for removing a foreign body.)