ED Coding and Reimbursement Alert

Question: A patient presents complaining of arm and finger pain, contusions to her upper arm and shoulder, and a glass splinter embedded beneath the skin on the right index finger. After taking an expanded problem-focused exam and expanded problem-focused history, the physician makes one incision over the FB site, permitting removal of the glass with splinter forceps. The area is then cleaned and secured with steri-strips. Is this a simple or complicated foreign-body removal?


Hawaii Subscriber


Answer: This encounter sounds like a simple FBR. Even though CPT offers no exact definition of -simple- or -complicated- FBRs, most payers will consider the procedure simple when:

- the physician removes the FBR via simple incision overlying a foreign body embedded in subcutaneous tissue.

- the FBR requires minimal debridement and no dissection.

Your scenario involved a single incision and no mention of debridement or dissection, so you-re best served by the simple FBR codes. On your claim:

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

- report 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem- focused history; an expanded problem-focused examination; medical decision-making of low complexity) for the E/M service.

- attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99282 to show that it was a separate service from the FBR.

- link 923.09 (Contusion of upper limb; multiple sites) and 915.6 (Superficial injury of finger[s]; superficial foreign body [splinter] without major open wound and without mention of infection) to 10120 and 99282 to prove medical necessity for the whole encounter.