ED Coding and Reimbursement Alert

Minor Procedures:

Follow These Steps to FBR Success

Published on Wed Jul 13, 2022

Deciding if an FBR is complicated is … complicated.

People engaged in summertime activities seem to be magnets for foreign bodies, which is why patients reporting for foreign body removals (FBRs) could be more common in your ED this time of year.

But coding them isn’t as straightforward as you think.

That’s because there are three different possible ways to code and bill for an FBR, as the case study below shows. Follow along and see if you know the different ways to code FBR encounters.

The Case

A patient reports to your office with a splinter embedded in the sole of her foot after running around on a wooden deck. Your provider removes the splinter at the encounter.

Evaluate This First FBR Solution

As this case study does not provide details regarding the method your provider used to remove the splinter, the first problem you have to solve before coding this encounter correctly is determining how the provider removed the foreign body.

The key word here is “incision.” If the provider does not make an incision into the patient’s foot, and instead removes the splinter “using tweezers or another implement, it would be considered part of an evaluation and management [E/M] visit. So, you should roll the work of the removal into the E/M,” suggests Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America.

In this case, the patient’s complaint can be regarded as an acute, uncomplicated illness, defined by CPT^®as “a recent or new short-term problem with low risk of morbidity for which treatment is considered,” and for which “there is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.” Additionally, the FBR itself presents a low risk of morbidity to the patient. These two low elements of medical decision making (MDM) combine to give an overall low MDM, enabling you to justify billing 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...) for the visit.

Know What to Do if Removal Methods Change

“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,” Hauptman suggests. In this case, you may be able to claim both the E/M and the incision service by coding for both, attaching 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.

Be Incisive With This Second Solution

If the FBR turns from an E/M to a removal by incision, or if your provider immediately uses a scalpel or other sharp instrument to cut into the patient’s skin to find and remove the foreign body in the encounter, two procedure codes may then come into play: 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (… complicated).

To determine which of the two you should use, you need to understand the difference between simple and complicated FBRs.

CPT^®does not offer a definition of “complicated.” Instead, factors such as “infection, scarring in the area, multiple foreign bodies, or delayed treatment,” may complicate the FBR removal, Bucknam explains. Removals involving exploration or debridement of the wound could also rise to the complicated level.

When that happens, you should leave the determination of the procedure’s complexity to your provider — simply put, if your provider has used the term “complicated” in the documentation, you can go with 10121.

Don’t Remove This Site-Specific Third Solution

The musculoskeletal surgery codes (20100-29999) also contain numerous FBR codes specific to various anatomic areas, including 28190 (Removal of foreign body, foot; subcutaneous), 28192 (... deep), and 28193 (... complicated). It is not impossible that your provider may have to go to these lengths to remove the splinter “if the foreign body is deeper, or if it involves the fascia,” says Bucknam.

The little-known complicated FBR from the foot code is worth remembering. The total facility RVUs for 2022 are significantly higher than for 28193 (10.75) than for 10120 (3.04).

Do this: If 28193 accurately describes the procedure performed, and you can back the code up with the proper documentation, use it. Using 28193 correctly could mean an additional $266.82 — or about two and half times — more than the payment for the simple FBR code 10120.