EM Coding Alert

Question: A patient reports to the ED after falling into a pile of branches while landscaping. The patient reports pain in their right pectoral area, and there is significant trauma there. The ED physician performs a physical exam, then decides to debride the wound to remove damaged tissue. After spotting a pair of wood fragments in the patient’s chest, the ED physician incises the right pectoral and removes them. How should I report this encounter? Is this a simple or complicated foreign body removal (FBR)?

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Answer: This encounter has all the markings of a complicated FBR. On the claim, report:

• 10121 (Incision and removal of foreign body, subcutaneous tissues; complicated) for the FBR
• Modifier RT (Right side) appended to 10121 to indicate laterality
• The appropriate-level evaluation and management (E/M) code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set for the E/M
• 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) appended to the E/M code to show that the FBR and the E/M were significant, separately identifiable services
• S20.151A (Superficial foreign body of breast, right breast, initial encounter) appended to 10121 and the E/M code to represent the patient’s injury
• W01.119A (Fall on same level from slipping, tripping and stumbling with subsequent striking against unspecified sharp object, initial encounter) appended to 10121 and the E/M code to represent the cause of the patient’s injury
• Y93.H2 (Activity, gardening and landscaping) appended to 10121 and the E/M code to represent the patient’s injury appended to 10121 and the E/M code to represent the activity the patient was engaged in when they were injured

More on complicated FBR: CPT^® does not define what constitutes a complicated FBR. There are many mitigating factors that could make a superficial skin FBR complicated, including infection, scarring in the injured area, multiple foreign bodies, delayed treatment, wound exploration, or debridement. Your patient’s FBR involved at least two of those factors, so you are free to report 10121.