ED Coding and Reimbursement Alert

Foreign Body Removal:

Master FBR Coding With 6 Quick Tips

Published on Mon Oct 11, 2021

From gunshots to splinters, understand when something qualifies as a foreign body removal.

You may not think of a bullet to the extremity or a tick embedded in the skin as a foreign body (FB), but when your ED physician has to remove one, you’ll need to determine whether it’s a FB or not so you can select the right code.

If you’re ready to master your foreign body removal (FBR) coding skills, consider these six key tips that can lead you on the right path.

Tip 1: Understand Which Instrument Was Used

In some cases, you won’t be able to accurately pinpoint the right code for foreign body removals unless you know which instrument the physician used to perform the removal. You can usually identify this information in the progress notes from the visit.

For instance, when it comes to 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 foreign body in the eye.

Therefore, 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: In other cases, however, you will have to identify the instrumentation used. For example, if your physician performs an FBR from the cornea, you will need to consider the visualization equipment involved: that is, whether the provider used 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 that are performed in the emergency department, 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 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 (Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)).

Tip 2: Understand Exploration vs. FBR

In some cases, such as when the ED physician is treating a gunshot wound, the provider is exploring the wound to assess and treat possible injuries to critical neurovascular structures, rather than just performing a foreign-body removal. Although this may seem minor, the detail is important to understand when selecting the right CPT^®code.

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. That’s because the physician typically removes the foreign body while exploring the injury site.

Tip 3: Know When Services Qualify as FBRs

You may come across instances where the physician removes an item — such as a tick or a splinter — that doesn’t actually qualify as a foreign body removal. In fact, if the physician makes no separate incision as part of the FBR, you cannot report an FBR code. Instead, you should count the FBR service toward the overall evaluation and management level you report for the visit.

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 3 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 a foreign body removal 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 the incision. If the physician has to perform extensive dissection to reach the foreign body and remove it, 23333 (Removal of foreign body, shoulder; deep (subfascial or intramuscular) would be the appropriate choice.

Tip 4: Documentation Should Dictate Simple vs. Complicated FBR

Your physician’s documentation should always dictate the code you choose, and if they have specifically stated that the FBR was simple, you must report 10120 for a simple incision and removal of an FB.

However, if the physician does not explicitly state that the FBR was simple or complicated, you will have to read deeper into the documentation to make a determination about which code best applies to the service.

Clues to complicated: Many physicians will refer to a complicated removal (10121, Incision and removal of foreign body, subcutaneous tissues; complicated) if the documentation mentions specific exploration, extensive cleansing/debridement, or extension of the wound.

Bright idea: Institute a policy on what criteria must be present for an FBR to qualify as complicated at your emergency department. 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. In addition, if your payer(s) have specific rules guiding you on simple vs. complicated, keep those up to date and use them as guidance when you are selecting the codes for these services.

Tip 5: Report One FBR Code Per Site

In some cases, the physician will remove several foreign bodies from the same site on a patient, but that doesn’t mean you can always report multiple FBR codes to bill for the extra work.

Here’s why: 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.

This policy can seem unfair when the physician clearly performs more work to remove many FBs. In the case of a shrapnel wound, for instance, 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 foreign body removal.

You’ll need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional 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.

Another option: You could also consider appending modifier 22 (Increased procedural services) to the FBR code to recoup your reimbursement 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.

Tip 6: Check the Musculoskeletal Codes

You should always check the musculoskeletal section of CPT^®by anatomical site section to verify the location-specific FBR codes, such as the three relevant to the foot 28190, 28192, and 28193, which have much higher relative value units (RVUs) assigned than the 10120 code.