General Surgery Coding Alert

Although any object or substance that is not part of the human anatomy can be considered a foreign body, this does not mean that foreign-body removal (FBR) codes may be used whenever such an object is extracted.

FBR codes appearing in the Surgery/Digestive System section (40000 series) of CPT are categorized according to anatomic site. The list covers endoscopic FBR from the intestine, stomach, colon, rectum and other sites.

Removals of extraluminal foreign bodies, however, are more complicated. The foreign body may be embedded at varying depths (through the skin, subcutaneous tissue, fascia, muscle and bone), each of which may trigger use of a code found elsewhere in CPT. Surgeons can report FBR using codes in the Musculoskeletal section (20000 series) of CPT even if the embedded body is in the subcutaneous tissue (otherwise considered part of the integumentary system).

Furthermore, the inadvertent discovery of a foreign body during an exploration may require a different code than a known foreign body that is purposefully removed.

To determine whether an FBR code is appropriate and which one to use, you should review the operative report for answers to four questions:

1. Did the surgeon have to make an incision to remove the object?

2. Was the surgery performed to remove the foreign body, or did the surgeon discover it while doing something else?

3. Where was the object?

4. How deep was the foreign body embedded?

If the foreign body is removed without an incision, an FBR code should not be billed, says Pamela Biffle, CPC, CCS-P, coding director with Concentra, a large occupational healthcare group in Addison, Texas. "For example, if the surgeon uses a pair of tweezers to remove a splinter, an FBR code should not be reported," she says.

These codes should also not be used if the surgeon discovered the foreign body while performing a wound exploration, Biffle says. In these cases, you should use wound-exploration codes 20100, 20101, 20102 or 20103.

For example, a patient may require that a percutaneous endoscopic gastrotomy (PEG) tube be removed. Although the PEG tube is a foreign object, the procedure should not be coded as FBR.

If a piece of the PEG tube breaks off and must be extracted, however, upper gastrointestinal endoscopy code 43247 may be billed.

Once it is determined that an FBR code is appropriate, the location and depth of the wound must be determined.

The Musculoskeletal section includes codes for the shoulder, humerus (upper arm) and elbow, hip, femur (thigh region) and knee joint, and feet and toes.

Each location includes one or more FBR codes. For example, FBR in the shoulder area may be reported as 23330, 23331 or 23332.

If the foreign body is embedded in subcutaneous tissue or anywhere else above the fascia, 23330 should be reported. If the surgeon must go below the fascia, use 23331. If the procedure is particularly complex, 23332 may be required.

FBR codes for the foot and toes are similarly classified, as follows: 28190*, subcutaneous; 28192, deep; and 28193, complicated.

FBR in other body areas may be described using two codes only usually subcutaneous (or superficial) and deep such as those for the upper arm and elbow (24200 and 24201) and for the hip (27086* and 27087).

Only one code (27372) is used for FBR from the femur or knee joint, and it must be deep.

Bodily areas that do not have their own FBR codes, such as the head, neck, flank, spine, abdomen, wrist/forearm and fingers, should be reported using 20520* (Removal of foreign body in muscle or tendon sheath; simple) or 20525 (deep or complicated).

If the foreign body is embedded above the fascia, the simple, superficial or subcutaneous codes should be used.

If the fascia is crossed, the deep codes (which reimburse at a much higher rate) should be reported.

If the surgeon requires fluoroscopic guidance to extract the foreign body and performs all the services, 76000 may also be reported. A separate radiology report is not required, but the use of fluoroscopy, as well as the location and depth of the wound, should be documented in the operative report.