ED Coding and Reimbursement Alert

Expert Q & A to satisfy your curiousity--and your bottom line

Don't lose your anatomical place--or your practice's deserved reimbursement--with tough foreign-body removal (FBR) cases. The type of removal and method may vary from patient to patient, but these field-tested answers will help you with the full range of possibilities.

Question: Should the instrument the doctor used determine which code I choose when the physician performs an FBR in the cornea or conjunctiva of a patient's eye?

Answer: Sometimes. For conjunctival foreign bodies, you will use code 65205 (Removal of foreign body, external eye; conjunctival superficial) or 65210 (... conjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating), and these codes do not indicate any particular instrument for removing the FB. You should choose a code according to the specific location and level of penetration of the FB in the eye.

For example, for the removal of a superficially penetrating FB in the conjunctiva, you would report 65205. The physician may use a cotton swab, needle, burr or other instrument, but this does not affect code choice.

Not so fast: If your physician performs an FBR in the cornea, you will need to consider the visualization equipment involved: that is, whether he uses a slit lamp to visualize the FB. Report 65220 (Removal of foreign body, external eye; corneal, without slit lamp) if the physician did not use the slit lamp; otherwise, report 65222 (... corneal, with slit lamp).

Method can matter: For most procedures in the ED, CPT does not specify which method the physician must use. But for those done elsewhere, there can be some variations. In addition to the examples above, there are other times when the FBR method will dictate your code choice.

For example, suppose a mentally handicapped patient has accidentally swallowed a small battery. Your physician may use an endoscope to remove the foreign body from the patient's stomach. If so, you would report 43247 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body).

Question: How should I code if my physician performs a significant exploration of a penetrating traumatic wound, such as a gunshot to the extremity?

Answer: In this case, your physician is exploring the wound to assess and treat possible injuries to  critical neurovascular structures, rather than a foreign-body removal.

Example: A patient presents with a small-caliber gunshot wound to the lower leg, and your physician explores the wound to evaluate for any damage to underlying nerves and blood vessels. Because this is a penetrating wound (gunshot, knife and some dog-bite wounds fit in this category), you should report 20103 (Exploration of penetrating wound [separate procedure]; extremity).
 
Note: Even if the provider had removed an FB during wound exploration, you should not report it separately because the wound exploration codes include FBR services.

Question: What is the rule for determining whether a splinter or tick removal counts as an FBR?

Answer: If the physician makes no separate incision as part of the FBR, you cannot report an FBR code, says Linda Martein, CPC, CPC-H, coding specialist with National Healing in Boca Raton, Fla. Instead, you should count the FBR service toward the overall evaluation and management level you report for the visit.

So, for example, if your physician removes a large splinter from a patient's arm without making a separate incision, you might report a low-level E/M code, such as 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), to describe the physician's work.

The same holds true for the removal of ticks, a procedure that usually doesn't require an incision. Remember, if the tick or splinter removal doesn't necessitate a separate incision, you should simply include the service in the appropriate-level E/M code.

In the case of incision: When a tick or splinter removal does require an incision, choose an incision and removal code based on the location of the FB and the extent of the incision.

For example, if your physician makes an incision to facilitate an FBR in a patient's shoulder, you would choose between 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) and 23330 (Removal of foreign body, shoulder; subcutaneous), depending on the extent of the FB and incision. If the physician has to perform extensive dissection, 23330 would be the appropriate choice, Martein says.

Question: What criteria should I consider to help me choose between a -simple- or -complicated- FBR in the skin?

Answer: Your physician's documentation should dictate the code you choose, and if she has specifically stated that the FBR was -simple,- you must report 10120 for a simple incision and removal of an FB, Martein says.

However, if the physician does not explicitly state that the FBR was -simple- or -complicated,- you will have to read deeper into the documentation. Warning: Coders commonly -overbill- for this service, says Cheryl Odquist, CPC, a reimbursement and compliance consultant with Codeology in San Diego--so think carefully before reporting a complicated FBR.

Clues to -complicated-: Report 10121 (- complicated) if the documentation mentions specific exploration, extensive cleansing/debridement or extension of the wound, Martein says. And don't hesitate to ask your physician if you suspect she determines simple or complicated FBR using different criteria.

Bright idea: Institute a policy on what criteria must be present for an FBR to qualify as complicated, Martein says. A written policy will safeguard you in the event of an audit, making your coding defensible as long as you coded according to the written policy, she says.

Question: If my physician removes several foreign bodies from the same site on a patient, can I report multiple FBR codes to bill for the extra work?

Answer: FBR codes generally do not specify -each- in the descriptor, meaning that you should not report them for -each- FB your physician removes. Instead, you should report only one FBR code per anatomic site, regardless of how many FBs are involved, Martein says.
 
This policy can seem unfair when the physician clearly performs more work to remove many FBs. In the case of a shrapnel wound, the provider may have to spend more than an hour removing various FBs from the wound site. But while you can only report one FBR code for this service, remember that you may also be able to report an appropriate E/M code to account for the assessment and medical decision-making the physician performed before starting the FBR, Martein says.

You-ll need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to recoup payment for both the E/M and the FBR, she says.
 
Another option: You could also consider appending modifier 22 (Unusual procedural services) to the FBR code to recoup for the extra work. To do this, you-ll need to submit a thoroughly documented operative report, a good explanation of the more extensive service, and a fair charge for the extra work.