ED Coding and Reimbursement Alert

If the removal does not meet procedure-code standards, report an E/M

Emergency department physicians are often called on to perform soft-tissue foreign-body removal (FBR) procedures -- especially in the summer months, when the warm weather results in more outdoor work and play. 
 
Reporting soft-tissue FBRs involves more than one code choice, so knowing exactly what constitutes an FBR -- and what doesn't -- is key if you want to file an accurate claim.
 
Confusion often arises when coders look at the notes and start asking themselves, -What constitutes a [foreign-body] removal?- says Linda Martien, CPC, CPC-H, coding specialist for National Healing Inc. in Boca Raton, Fla.
 
Try this: According to Robert LaFleur, MD, FACEP, of Medical Management Specialists in Grand Rapids, Mich., when you are considering whether or not an encounter was an FBR, you-ll need to determine:

 - the complexity of the removal
 - whether the physician performed an incision during the procedure
 - the anatomical location of the removal.

Once you-ve addressed these issues, you should be prepared to pick the proper FBR code.

Most ED Removals Are Simple
 
ED coders should first decide whether the procedure was a simple or complex removal. For a simple soft-tissue FBR, you would report 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the encounter.
 
Consider this example, courtesy of Martien: A carpenter presented with a nail embedded in his right thigh; he accidentally shot himself with a compressed-air nail gun. The nail is buried in the skin and subcutaneous tissues, and the nail head is palpable under the skin.
 
The ED staff cleaned and prepped the wound, and the physician anesthetized the injury site. He then cut a tiny -X- over the nail head and used forceps to grip the nail and remove it. Staff then cleaned the wound again and applied antibiotic ointment. The physician closed the incision with a Steri-Strip and applied a dry dressing.
 
On the claim, you should:
 - report 10120 for the nail removal.
 - link ICD-9 code 890.0 (Open wound of hip and thigh; without mention of complication) to 10120 to represent the patient's injury.
 - link E920.1 (Accidents caused by cutting and piercing instruments or objects; other powered hand tools) to 10120 to represent the accidental cause of the patient's injury. (Use E920.1 to represent injuries caused by any powered hand tool powered by compressed air such as our nail gun.)
 
Diagnosis coding matters: When you submit a claim for soft-tissue FBR, the payer will be scrutinizing your choice of diagnosis codes, Martien says. In the above example, you must code the injury, and the E codes are also helpful for added accuracy in describing the accident.
 
Exception: Most of your soft-tissue FBRs in the ED will be simple. However, if your physician performs a complex FBR, you should choose 10121 (... complicated) rather than 10120.
 
Complex soft-tissue FBR is not performed as often in the ED since these presentations are less common. Complex FBRs usually involve some radiographic guidance, which is becoming increasingly available to ED physicians, says Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems (MRSI), an ED billing company in Stoneham, Mass. Hallmarks of complex FBR may include localization techniques with a C-arm fluoroscopy device, ultrasound, or plain x-ray with radiographic markers and extensive dissection, Granovsky says.  

Include Incision in 10120, 10121

Coders cannot presume to report all soft-tissue FBRs with 10120 or 10121. When the ED physician removes a foreign body from a patient, it does not always qualify as a 10120-10121 service.
 
Why? According to CPT guidelines, the doctor must make an incision in order for a service to qualify as an FBR falling under 10120 or 10121. -For instance, removing a splinter with a tweezers is not considered an FBR because the splinter was not excised,- Martien says.
 
According to LaFleur, many FBRs do not qualify as FBR procedures, at least according to the CPT definitions.  -The incision is the problem here. There are many FBRs in which the FB itself has made a laceration through which the physician can work, eliminating the need for another incision. But the codes as strictly interpreted call for [the doctor to make] an incision,- LaFleur says.
 
If your physician did not incise during the procedure, report the proper-level evaluation and management code instead of 10120 or 10121.
 
The E/M level in these scenarios could be as high as a level four depending on the location and nature of the foreign body and other complicating factors, such as oral Rx drug management or IV antibiotics.
 
Also: There are special reporting rules for FBRs from feet. For information on how to code these encounters, see -Flip to This Code Set for FBRs of the Foot- below.
 
Note: Ready to tackle a soft-tissue FBR coding scenario? Check out this month's You Be the Coder on page 52.