ED Coding and Reimbursement Alert

Question: A construction worker was handling old wood when a piece split and lodged in his right forearm. He was current on tetanus, and he had no further injuries. The physician reviewed the patient's vital systems (stable), but concentrated the rest of the exam on the right arm. There was a palpable foreign body on the volar aspect of the forearm. The end of the wood piece was visible at the entrance wound, but tightly wedged against the patient's skin.
 
The physician sterilized the arm, prepped it with betadine and anesthetized the area with lidocaine. He then enlarged the opening of the entrance wound to free up the end of the sliver. Using a hemostat, the physician removed the wood piece entirely intact. The physician cleaned the wound but did not close it, and applied dressing.
 
How should I code this encounter?

California Subscriber

Answer: Since the physician performed an incision to free up the end of the sliver, this qualifies as a soft- tissue FBR. On the claim, you should:

 - 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; and medical decision-making of low complexity) for the E/M service.

 - append 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 the E/M service was separate from the FBR.

 - attach ICD-9 codes 881.00 (Open wound of elbow, forearm and wrist; without mention of complication; forearm) and E920.8 (Other specified cutting and piercing instruments or objects) to 10120 and 99282 to prove medical necessity for the encounters.

 -- Clinical scenario and answer to You Be the Coder were provided by Robert LaFleur, MD, FACEP, of Medical Management Specialists in Grand Rapids, Mich.