ED Coding and Reimbursement Alert

 Don’t sacrifice pay for these common problems.

Emergency department providers don’t often perform surgeries, but one service that you may find yourself treating occasionally is foreign body removals. There are only two codes for subcutaneous FBR, but a lack of knowledge when coding the services could mean a lack of deserved reimbursement for your provider’s FBR claims.

Check out this quick primer on the ins and outs of subcutaneous, or soft tissue, FBR coding.

Here Are the FBR Coding Basics

For subcutaneous FBRs, you’ll report 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 ( … complicated), depending on encounter specifics.

Simple, right? Well, yes and no. Here’s a rundown on the FBR basics, from Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington:

An FB “is a foreign body in the subcutaneous tissue, just below the dermis. The foreign body could be anything including a thorn, a splinter, or something left medically like an embedded staple or stitch that … was intended to be left in place but is moving out of the body and is now in the subcutaneous tissue.”

Also, “it’s worth noting if the foreign body is deeper or if it involves the fascia, this should be coded in the musculoskeletal system” section of CPT^®. Failure to code deeper FBRs with codes other than 10120 and 10121 will result in a serious loss of money, Bucknam adds.

There are rules for coding 10120 and 10121 that mean your provider has to go beyond pulling a splinter out of a patient’s finger to qualify as an FBR.

Explanation: If there is no evidence that the provider made an incision during the procedure, you cannot report 10120 or 10121, Bucknam confirms. “If the physician can just take a forceps and grasp the foreign body and pull it out, then there is no separate coding for the service,” she says.

Don’t Misstep in Coding FBR From Foot

There are separate codes specifically for removing a foreign body from a foot. 28190 (Removal of foreign body, foot; subcutaneous) 28192 (…; deep) and 28193 (…; complicated). These codes pay almost a full RVU more than the general FBR codes. For example, 10120 has 2.96 total facility RVUs and a $106.68 Medicare payment as opposed to 28190 with a 3.85 total facility RVUs and a Medicare payment of $ 138.75. The complicated foot code 28193 has a 4.23 total facility RVUs and a Medicare payment of $383.46.

Take away: Choose the code that accurately describes your procedure but be aware of all your choices.

Use E/M When Incision not Indicated

If you can’t use 10120 or 10121 when the ED provider removes a foreign body, you should roll the work of the removal into the work units when choosing the evaluation and management (E/M) code, says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director of compliance audit at Cancer Treatment Centers of America.

“If the physician uses tweezers or another implement, it would be considered part of an [E/M] visit,” she explains. “The detail would be included in the skin examination and depending on the information, you might count it toward a detailed examination; perhaps part of the 1997 integumentary examination, if all other elements are present.”

There are limits to how long the provider should try to remove a foreign body before making the incision decision, Hauptman says. “The physician should set a limit on these types of removal; it could be a time limit or an implement limit. After using certain tools without success or after trying for a period of time, an incision might be the best approach. All of this should be detailed within the medical record.”

Be Ready When Things Get Complicated

While 10121 encounters are not always the first consideration, coders need to be ready to identify these procedures.

There is no standard definition for what makes a subcutaneous FBR “complicated.” The complication could be “infection, scarring in the area, multiple foreign bodies, delayed treatment, etc.,” Bucknam explains.

Documentation tip: The ED provider should ideally make the determination on whether FB removal is completed and use the term “complicated” when describing the procedure.

Best bet: Use this advice as a guide, and check with your provider, to make sure you are meeting the appropriate definition of complicated.