ED Coding and Reimbursement Alert

Look for these op note details to spot a complicated soft-tissue FBR

While patients typically don't present to the ED with complicated FBs, there is always a chance a physician may be called on to perform a complicated soft-tissue FBR. When this occurs, you should code the service with 10121 (Incision and removal of foreign body, subcutaneous tissues; complicated).

What to look for: Complex FBRs will often involve radiographic guidance, says Michael A. Granovsky, MD, CPC, FACEP, president of Medical Reimbursement Systems Inc. (MRSI), an ED billing company in Stoneham, Mass.

A complex soft-tissue FBR may also involve localization techniques with a C-arm fluoroscopy device, ultrasound, or x-rays with radiographic markers and extensive dissection, Granovsky says.

Consider this example:

A carnival worker who operates the Ferris wheel presents stating that while the ride was in motion, a gear got stuck. The worker went underneath the machine to check it out and was injured by a piece of flying metallic debris. He says it feels as if there is -something stuck- in his forearm.

The ED physician performs a level-three ED E/M service and attempts to localize the foreign body. On exam she can palpate something beneath the skin, but attempts to locate the foreign body (including making an incision) fail. Under C-arm fluoroscopy guidance, the physician localizes a 1-cm foreign body.

Under C-arm guidance, the physician cuts down on the foreign body and is able to fully remove it. The wound is then left open, and the patient is placed on antibiotics.

On the claim, you should:

- report 10121 for the complex FBR.

- append 913.6 (Superficial foreign body [splinter] without major open wound and without mention of infection; elbow, forearm and wrist) to 10121 to represent the FB.

- report 99283 (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; moderate-complexity medical decision-making) for the E/M.

- append 959.3 (Injury; elbow, forearm, and wrist) to 99283 to represent the forearm injury.

- attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99283 to show that the E/M and FBR were separate services.