ED Coding and Reimbursement Alert

If you cannot spot simple or complicated foreign body removal (FBR) qualifiers,you could end up costing the ED more than $80 for a simple removal, or more than double that per complex episode. Galvanize your soft-tissue FBR coding skills with this expert advice.

Coding for soft-tissue FBRs seems simple enough: A patient reports to the ED with an FB, the physician removes it, and you choose an FBR CPT code.

Not so fast: The above scenario might be an FBR, but it might also be an E/M service. To report one of the soft-tissue FBR codes, the encounter should fit the following description, from Joshua Tepperberg, CPC, EMT-D: The provider makes an incision to the overlying skin, and then removes the FB.

Wound closure is typically included in the FBR code, if necessary. -And the provider must make an incision- to report a soft-tissue FBR code, stresses Tepperberg,who is ED coding team leader at Caduceus Inc. in New York City.

Example 1: Let's say a patient reports to the ED with a wood splinter in his left hand. The ED physician examines the wound and cleans the area around it. Using a pair of tweezers, the physician pulls the entire splinter out of the patient's hand. Since there was no incision, this is an E/M, confirms Pamela Cline, RHIT, senior coding supervisor for Medical Account Services in Frederick, Md.

For Example 1, you-d report a low-level E/M 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 ...).

Example 2: A construction worker reports to the ED with a carpentry nail lodged just under the skin in his left forearm. The physician cleans the area around the wound, and then makes several attempts to grab the nail head with a pair of tweezers. The nail head, however, cannot be gripped properly, so the physician makes a tiny -X- incisionwith a scalpel and pulls the FB out with tweezers.

Notes indicate the physician performed a level-two E/M in addition to the FBR. For Example 2, you-d report the following:

- 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the FBR

- 99282 for the E/M

- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99282 to show the FBR and E/M were separate services.

There may be some instances where the physician does not make a standard -incision- with a scalpel, but you can still code a soft-tissue FBR, explains Debra Williams, CPC, billing supervisor at Horizon Billing Specialists in Grand Rapids, Mich.

-Some think an incision must be made with a blade,- Williams says. But the physician can also make an incision with a needle or other surgical device and report soft-tissue FBR codes.

For example, suppose a patient presents with a shard of glass wedged in the skin of her hand. The ED physician uses a 22-gauge needle to unroof the area and then removes the shard with surgical tweezers. The incision in this case is made with the 22-gauge needle through the unroofing process.

While not as common in the ED as simple FBRs, you-ll also need to be able to spot claims in which the physician performs a complicated FBR -- if you want to legitimately fatten the practice's bottom line.

Payoff: CPT code 10120 pays an average of $83 (2.30 transitional facility RVUs multiplied by the Medicare conversion rate of 36.0666). CPT code 10121(- complicated) pays approximately $170 (4.72 RVUs multiplied by 36.0666).

Be careful when reporting 10121, as a complicated FBR claim must prove the extra work and decision making needed to perform the procedure.

Complicated FBRs are categorized by an FB -embedded deep within the subcutaneous tissue. This [procedure] may require dissection of underlying tissue- to locate the FB, Cline says.

According to Sharon Richardson, RN, compliance officer with Emergency Groups- Office in Arcadia, Calif., a complicated FBR might also include one or more of the following:

- x-rays

- fluoroscopic guidance

- ultrasound

- debridement.

Example: A construction worker presents to the ED after a drilling accident: the drill bit shattered while he was using it, embedding a metal fragment within his arm. The physician can feel it on palpation, but cannot localize the fragment after making an incision. Under x-ray guidance, the physician performs extensive dissection, then localizes and removes the foreign body. For this more complex procedure, you would report 10121.

Note: The FBR rules discussed in this article do not apply to foot FBRs, which have their own codes and rules. For more information about coding foot FBRs, see the next article.