ED Coding and Reimbursement Alert

Because CPT does not offer specific guidelines to distinguish simple from complicated foreign body removal, ED coders may have difficulty choosing between 10120* (incision and removal of foreign body, subcutaneous tissues; simple) and 10121 (... complicated).

Supporting the Codes

The physicians documentation is most important when determining the level of the removal, and must support the coding during an audit. The coding relies on [the physicians] medical decision-making. I dont feel qualified, nor do I think any other nonclinician should feel qualified, to determine that. If [the documentation] doesnt specify complicated, I wouldnt assume that it was, says Charlene Endre-Day, CMA, CMM, CPC, director of professional relations for Team Physicians of Arizona, which works in hospital-based physician services.

Also, an x-ray doesnt always mean the removal is more complicated, Endre-Day explains. It just means the physician is looking to see how deep the object is, or if there are other particles in there for example, when removing a BB thats spread or scattered. Although the removal may be complicated, the x-ray isnt the deciding factor, she says, but rather what the physician does during the removal.

Answer Five Key Questions

Because documentation must support the coding, there are five questions that coders should ask themselves when choosing between the simple and complicated foreign body removal codes:

1. Did the physician specify simple or complicated?
2. Was vascular compromise mentioned?
3. Was significant exploration mentioned?
4. Was extensive cleansing and/or debridement performed?
5. Was extension of the wound required?

If the physician specifically states the removal is simple, the coder should defer to the physicians expertise and code accordingly.

If you answer yes to any of the other above questions, consider the removal complicated or check with the physician who most commonly performs the service to determine how he or she differentiates between simple and complicated.

Are Splinter Removals Too Simple?

There is a lot of discussion on correct coding for splinter removal, explains Mason Smith, MD, FACEP, president of Lynx Medical Systems, a medical software and coding consulting firm in Bellevue, Wash. If I dont make an incision, should I bill for a splinter removal? I think the answer is generally No. Its not a procedure if I can just pluck it.

Smith does not consider a splinter simple because the definition of 10120 clearly states incision and removal of foreign body. The whole principle of billing for a procedure is that it is a discrete service of sufficient magnitude to warrant a separate charge. It must be more than you would do in the typical E/M, he explains.

Going Beyond Complicated

In some cases, a complicated foreign body removal may require the presence of a specialist, such as a surgeon or orthopedist (for instance, if it is vascular-related). In such cases, surgery codes other than 10121 which are selected according to where the foreign body was located may be appropriate.

The muscular/skeletal portion of CPT is arranged according to anatomic area. Generally, contained within the individual sections devoted to each body part there is a code for removal of a foreign body. For example, 27372 (removal of foreign body, deep, thigh region or knee area) describes foreign body removal from the femur and the knee joint.

If the [ED physician] performs the removal him- or herself, he or she can code for it, Endre-Day advises. Again, however, when using these codes in the ED, documentation must support the claim.