ED Coding and Reimbursement Alert

Question: A 12-year-old male patient presented with complaints of a swollen foot. He had been running barefoot at a picnic three days earlier, but didn’t experience any discomfort until yesterday, when his foot “started hurting really bad.” He reported a six out of 10 on the pain scale. Our physician noticed that the patient’s heel was swollen and leaking pus. Upon examination, the doctor reported finding a foreign body (FB) in the patient’s heel; notes indicated it was most likely a wood splinter. The clinician was unable to remove the FB with only tweezers, so he used a scalpel to make an incision, removed the FB with tweezers from the patient’s subcutaneous tissue, dressed the wound, and sent the patient home. How should I report this encounter?

Codify Subscriber

Answer: You’ll report a code for the foot foreign body removal (FBR) and, most likely, an E/M code for the service that preceded the FBR. On the claim, you would report 28190 (Removal of foreign body, foot; subcutaneous) for the FBR.

Then — due to the likelihood of a requirement for an E/M service, if documented, — you would report a code from the 99281-99285 series.

Remember:  If you do report a separate E/M, be sure to append 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 to show that the FBR and the E/M were separately identifiable services.

Since it appears your clinician performed a separate FBR before arriving at the 28190 decision, a separate E/M is possible.