ED Coding and Reimbursement Alert

Step up your coding on feet FBRs, sprains and application of casts and splints

Feet get stepped on all day, toes get stubbed, and ankles get sprained. Don't miss this expert advice on common ED foot presentations.

Foot Foreign Bodies

Choosing the correct code to assign when a patient has a foreign body removed from the bottom of her foot isn't always easy. Many coders default to the standard foreign body code 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) without digging into the CPT^® book a little deeper. According to Todd Thomas, CPC, CCS-P, President of ERcoder, Inc in Edmond OK, there are several body sites that have their own foreign body removal codes and the foot is one of them. CPT^® has three foot specific foreign body removal codes:

28190 (Removal of foreign body, foot; subcutaneous)
28192 (Removal of foreign body, foot; deep)
28193 (Removal of foreign body, foot; complicated)

As indicted above, the CPT^® description for 10120 means the physician must make an incision to remove the foreign body as opposed to removing it with forceps. Also 10120 is listed in the Integumentary section so typically the foreign body would be at the skin level but the 2819X foot FBR codes are listed in the Surgical section and often require a deeper location. The description for the site-specific codes do not include the requirement for an incision. Consider the following examples to see how this concept applies.

Foreign Body Foot Patient 1

HISTORY OF PRESENT ILLNESS

Chief Complaint: Injury to the right 2nd toe. (glass) The injury happened about 4 days ago,

The patient sustained a laceration from broken glass. Occurred at home. The patient complains of pain on weight bearing. She has had swelling, weakness, and numbness. No tingling, suspected foreign body or skin laceration.

Extremities Exam: Right foot: mild erythema and tenderness and suspected foreign body in the subcutaneous tissues of the ball of her foot. Neurovascular intact distally.

PROGRESS AND PROCEDURES

Removal of Soft Tissue Foreign Body: The foreign body was glass. Located in the right foot. Prior to the procedure, the risks, benefits and alternatives to the procedure were explained. Local anesthesia provided using 1% lidocaine. Wound prepped with Betadine. Using forceps and hemostat moderate exploration was undertaken through the laceration and a small glass shard was identified in the subcutaneous tissues and removed. Dressing applied. Tetanus immunization up-to-date.

Foreign Body Foot Patient 2

HISTORY OF PRESENT ILLNESS

Chief Complaint: Injury to the right foot. The injury happened today about 12 noon. Patient stepped on a pile of branches and sustained a puncture wound, patient is unable to locate a foreign object. Patient is experiencing mild pain. Patient denies other injury.

Extremities Exam: Right foot, plantar aspect: suspected deep foreign body of the middle and medial aspect of the foot. No ankle injury. Foot and ankle exam otherwise negative. Extremities otherwise negative.

PROGRESS AND PROCEDURES

Removal of Soft Tissue Foreign Body: Time-out completed immediately before the procedure. Located in the right foot. Prior to the procedure, the risks, benefits and alternatives to the procedure were explained and consent was obtained. Local anesthesia provided using 1% lidocaine with epinephrine. Wound prepped with Betadine. Incision made with a #11 blade. Wound irrigated. Wound explored extensively and margins extended. Foreign body was visualized and appears to be imbedded in the deep tissues of the foot with a portion into the fascia. The foreign body was removed; bleeding was controlled without additional complications. Dressing applied. Tetanus immunization up-to-date.

So What Does That Note Suggest?

In the above examples the foreign bodies were removed from the bottom of the foot, but the procedure for patient 1 did not include an incision. This would most accurately be reported with CPT^® code 28190. The procedure for patient 2 did include the incision, so it would meet the requirements for 10120 but since the foreign body penetrated deep into the fascia the more accurate code would be 28192.

Accurately identifying these codes can have a significant impact on reimbursement, says Thomas. If the procedure for patient 1 were deemed not billable due to the lack of an incision the practice would lose the 3.85 RVUs associated with correctly reporting 28190. If the procedure for patient 2 were reported with 10120 the reimbursement would be 2.95 RVUs, instead of 9.02 RVUs for correctly reporting 28192 for the more involved and extensive deep foreign body removal, Thomas explains.