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ED Coding and Reimbursement Alert

You Be the Coder:

FB or Not FB, That Is the Question!

Published on Wed Mar 21, 2012

Question: What procedure and diagnosis codes would you assign to this case?A 43 -year- old patient eloped from the ED with his peripheral IV in place and returned five days later complaining of FB sensation in his arm. He may have taken it out himself while intoxicated but is not sure.The physician documentation stated: "Attempted to remove possible FB visualized with ultrasound. In sterile fashion, the area of pain and palpable hard mass was incised & bluntly dissected. There appeared to be a thrombosed blood vessel. No foreign body was palpated or visualized. The 2.2 cm wound was closed in sterile manner with 4.0 vicryl & the skin with Dermabond, patient tolerated procedure well. Final diagnosis, thrombosed superficial upper extremity vein.Counseled patient regarding the slight risk of retained FB but US I&D under direct visualization revealed only clots. - no FB identified."Answer:  99284-25 (Emergency department visit for the evaluation and [...]
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