General Surgery Coding Alert

Location and depth are crucial--but not enough--to guide your code selection

If the surgeon removes any object not part of the human anatomy, he technically performs a foreign body removal (FBR). Unfortunately, this straightforward logic doesn't carry over into coding principles.

To be sure you-re reporting FBR procedures appropriately, you-ll have to answer four questions.

1. Was an Incision Required?

If the surgeon can remove the foreign body without making an incision (or using a scope), you won't report an FBR, says Linda Martien, CPC, CPC-H, coding specialist with National Healing in Boca Raton, Fla. In such cases, you-ll likely be able to report only an E/M service at the level best supported by the physician's documentation of the patient encounter.

Example 1: The surgeon uses tweezers to remove a splinter from an elderly patient's left forefinger, applies antibiotics and dresses the wound.

Because the physician need not make a separate incision in this case, you cannot report an FBR code (although the surgeon did--in the strictest sense--remove a foreign body). Instead, you will report an appropriate E/M service code (for example, 99212, Office or other outpatient visit for the evaluation and management of an established patient ...).

Example 2: The patient arrives for a follow-up office visit for the purpose of removing a percutaneous endoscopic gastrotomy (PEG) tube. The surgeon removes the tube without complication.

Here again--although the PEG tube is a foreign object--you should not report an FBR code. The surgeon did not have to perform an -invasive- procedure, either via an incision or by using a scope, to remove the PEG tube. Therefore, you can only report an E/M code for the service.

Alternative scenario: Suppose, however, that a portion of the PEG tube broke off during removal, requiring the surgeon to use a scope to extract it.

In this case, because the surgeon had to use the scope, you may report FBR using upper GI endoscopy code 43247 (Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with removal of foreign body).

Reasoning: Although Chapter 6 of the National Correct Coding Initiative (NCCI) stipulates that -CPT code 43247 is not to be reported for routine removal of therapeutic devices previously placed,- this is not a -routine removal.-

In this case, there is no way to remove the portion of PEG tube manually. Your documentation should make clear, however, the necessity for using the scope to retrieve the portion of the broken tube. Without documentation, the payer will likely reject the claim.

2. Was the FBR -Incidental-?

You should also not report FBR if the surgeon discovers and removes a foreign body during wound exploration, Martien says. In such cases, the FBR is incidental to the exploration, and you would report only the exploration codes (for example, 20100-20103, Exploration of penetrating wound [separate procedure] ...).

By the same token, you will generally not report FBR if the removal occurs as a part of any more extensive procedure in the same area.

Example: During recurrent hernia repair (for example, 49520, Repair recurrent inguinal hernia, any age; reducible), the surgeon must remove mesh placed during a previous hernia repair.

Although you might argue that removing mesh constitutes FBR, payers simply will not recognize a separate code for the service. The mesh removal is instead considered incidental to the primary procedure (the recurrent hernia repair).

Learn more: For complete information on mesh placement and removal, see -4 Rules Help You Take the Mess Out of Mesh,- on page 4 of the January 2006 General Surgery Coding Alert.

3. What Was the Location?

When you have determined that a separate FBR code is the appropriate choice, you must next narrow your code selection by anatomic location.

Tip: Endoscopic FBR codes appearing in CPT's Surgery/Digestive System section (40000 series) cover the intestine, stomach, colon, rectum and other sites.

Examples of endoscopic FBR include 43247, 44363 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of foreign body) and 44390 (Colonoscopy through stoma; with removal of foreign body), among others.

FBR codes for extraluminal bodies are likewise arranged by location.

The Musculoskeletal section of CPT, for instance, 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, according to depth.

Example: You may report FBR in the shoulder area using 23330 (Removal of foreign body, shoulder; subcutaneous), 23331 (... deep [e.g., Neer hemiarthroplasty removal]) or 23332 (... complicated [e.g., total shoulder]), depending on the depth of the foreign body (see below).

FBR codes for the foot and toes are similarly classified as 28190 (subcutaneous), 28192 (deep) and 28193 (complicated), while codes for the upper arm and elbow (24200 and 24201)--as well as the hip (27086 and 27087)--give only two choices: superficial/subcutaneous and deep.

Tip: You may report FBR from body areas that do not have their own FBR codes, such as the head, neck, flank, spine, abdomen, wrist/forearm and fingers, using 20520 (Removal of foreign body in muscle or tendon sheath; simple) or 20525 (... deep or complicated), Martien says.

4. How Deep?

As indicated by the code descriptors listed above, the final consideration when choosing an FBR code is the depth of the object removed.

Your physician's documentation should dictate the code you choose (simple or deep/complicated). If the physician does not explicitly state that the FBR was -simple- or -complicated,- however, you will have to read deeper into the documentation.

Warning: Coders commonly -overbill- for this service, says Cheryl Odquist, CPC, a reimbursement and compliance consultant with Codeology in San Diego--so think carefully before reporting a complicated FBR.
 
General guidelines: If the foreign body is embedded above the fascia, you should call on the simple, superficial or subcutaneous codes. If the object crosses the fascia, choose the -deep- codes.

Example: The patient is involved in an auto accident in which several pieces of glass become embedded in his right shoulder. He is otherwise unharmed.

The surgeon removes the glass from the patient's shoulder. Much of the glass penetrates to the area below the fascia. In this case, you should report 23331.

Had the FBR been even more extensive, involving multiple removals from deep within the skin, 23332 might be more appropriate, depending on the strength of the surgeon's documentation.