ED Coding and Reimbursement Alert

Location and means of extraction will usually determine the code selection

A common presentation to the ED involves extracting a foreign body that the patient is unable to remove on his own. To finesse your FBR coding, you’ll need to look for anatomic location, depth of tissue penetration, and technique of removal. Check out these FBR coding strategies, provided by Todd Thomas, CPC, CCS-P, President of ERcoder in Edmond, OK.

Top FBR culprits: Little kids are notorious for putting small object in their ears or up their noses. Adults sometimes require extractions of a different nature, but equally challenging to perform. There are also injuries involving fishhooks or glass shards that also must be safely removed and treated.

Breathe Easy With These Nasal FBR codes

Choosing the right code for removing a foreign body from the nose will depend on how difficult it is to extract the technique used for the extraction and whether anesthesia is required. Options include water irrigation, forceps, cerumen loops, right angle ball hooks and suction catheters, says Thomas.

The codes for nasal and ear FBR appears below:

• 30300 (Removal foreign body, intranasal; office type procedure)
• 30310 (Removal foreign body, intranasal; requiring general anesthesia)
• 30320 (Removal foreign body, intranasal; by lateral rhinotomy)
• 69200 (Removal foreign body from external auditory canal; without general anesthesia)

Look for an Incision Before Coding FBR

 The surgery section of CPT^® contains two codes for removing foreign bodies, but both descriptors include the word “incision” in the descriptor. The incision must be documented in order to report these codes, Thomas explains.

• 10120 (Incision and removal of foreign body, subcutaneous tissues; simple)
• 10121 (Incision and removal of foreign body, subcutaneous tissues complicated)

Be aware: CPT^® does not define the terms simple and complex in these codes, so the choice of code is at the physician’s discretion, based on the level of difficulty involved in the incision and drainage procedure.

These two codes are the standard “go to” codes for FBR, but Thomas reminds coders that foreign bodies that are deep or complicated may be more accurately coded with the site specific codes.  FBR from the shoulder, arm (upper and lower have different codes), elbow, hip, leg (upper only) and foot all have site specific codes that may apply if the procedure fits the CPT^® description.

Coders should also be aware that the incision rule only applies when the CPT^® description indicates that an incision is required.  Many of the site-specific FBR CPT® codes do not include “incision” in the descriptor. The most common example for ED coders is code 28190 (Removal of foreign body, foot; subcutaneous). In this code descriptor, there is no mention of the incision as a requirement, Thomas explains.

Example: A 47-year-old male reports to the ED complaining of a painful, swollen, and reddening right thumb after a woodworking project. The physician performs an expanded problem focused history and examination, which uncovers two splinters. The ED physician cannot grasp the splinters with tweezers, so she uses a scalpel to make two small incisions above the splinters. The physician then uses tweezers to remove both pieces of wood. The notes do not indicate evidence of infection at the extraction site; medical decision making is low.

Since the physician made an incision before removing the splinters, this is an FBR. On the claim, report the following:

• 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the FBR
• 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 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 that the E/M and FBR were separate services
• 915.6 (Superficial injury of finger[s]; superficial foreign body [splinter] without major open wound and without mention of infection) appended to 10120 and 99282 to represent the patient’s injury.

Explanation: The incision, or lack of it, drives code choice in this scenario. If the physician had removed the splinters without making an incision, you would have rolled the removal work into the E/M service and left 10120 off the claim.

Kick It Up A Notch to Penetrating Trauma FBRs

The wound exploration-trauma, (e.g., penetrating gunshot, stab wound) codes describe surgical exploration and enlargement of the wound, extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or coagulation of minor subcutaneous and/or muscular blood vessel(s), of the subcutaneous tissue, muscle fascia, and/or muscle, not requiring thoracotomy or laparotomy.

• 20100 (Exploration of penetrating wound [separate procedure]; neck)
• 20101 (Exploration of penetrating wound [separate procedure]; chest)
• 20102 (Exploration of penetrating wound [separate procedure]; abdomen, flank, back)
• 20103 (Exploration of penetrating wound [separate procedure]; extremity)

Look Out For Location and Depth Documentation For Eye FBR Codes

CPT^® has a small section of FBRs form the eye. The correct choice will depend on how deep the FB is embedded, such as superficial conjunctiva or embedded conjunctiva. Use of a slit lamp to visualize the FB also impacts code selection, says Thomas.

• 65205 (Removal of foreign body, external eye; conjunctival superficial)
• 65210 (Removal of foreign body, external eye; conjunctival embedded [includes concretions], subconjunctival, or scleral nonperforating)
• 65220 (Removal of foreign body, external eye; corneal, without slit lamp)
• 65222 (Removal of foreign body, external eye; corneal, with slit lamp).