Internal Medicine Coding Alert

Snag $100 more for removal from foot " Codify shows you how.

If you automatically look to 10120 when an internist removes a tick, splinter, or other foreign body from a patient's foot, you could be forfeiting almost $100 per claim.

Better: You won't shortchange your physicians on foreign body removal (FBR) provided you follow these guidelines.

1. Before Using 10120, Check for Incision

Don't assume foreign body removal is a shoe-in for CPT integumentary section code 10120 (Incision and removal of foreign body, subcutaneous tissues; simple). The code requires incision. This can be, for example, a needle to remove a splinter or a scalpel to remove a glass shard.

Hint: Look for a sharp object when considering 10120. If the documentation doesn't include this detail, use an E/M service code (such as 99201-99215, Office or Other Outpatient Services) instead of the skin FBR code.

2. Rule Out Site-Specific Code Using 2 Details

CPT contains higher paying site-specific codes for foreign body removed from the musculoskeletal area and anatomic system sections. To see if the removal qualifies for a site-specific code, look for two details:

Example: An internist removes a splinter in the fascia of a patient's foot. In this case, you'd switch from 10120 to 28190 (Removal of foreign body, foot; subcutaneous), which will net you an additional $99.56. The 2010 Medicare National Physician Fee Schedule pays 10120 nationally $127.21 (3.45 relative value units [RVUs]) compared to $226.77 (6.15 RVUs) for 28190.

Example: Documentation indicates, "skin grad shaved until 1mm dk fb removed, simple." "Should this be coded with 10120 or 28190?" asks an internal medicine Codify discussion member. Since the note does not mention fascia and "1 mm dk" (dark) is insufficient to tell whether the incision goes into the subcutaneous tissue as 28190's descriptor requires, use 10120.

3. Quickly Find Site Specific Code Using These Options

Since CPT places the anatomic FBR codes in the corresponding system section, finding a site-specific FBR code can be like looking for a needle in a haystack. You can easily locate a site specific code using one of these methods:

Manual: In the alphabetical index, look up "Removal: Foreign Body". Then, scan through the available sites for site specific options.

Electronically: Under Codify's CPT Index, go to "R". Look down the "Removal" entries until you find the appropriate one. Some possibilities that internists might use include FBR:

4. ID Site Specific Complexity

You'll notice that under the integumentary and anatomic FBR codes, CPT offers options for the removal's difficulty. Many FBR code families include a simple and then a complicated code, such as 10120 and 10121 (... complicated).

Internists typically perform simple FBRs. However, your internal medicine, especially if it offers urgent care, may encounter FBRs that are complicated.

Key words: In the original example, the internist made coding easy by indicating "simple". Complicated means the FBR was harder than usual to remove. In these situations, the note should indicate, for example, extended exploration around the wound site, sometimes with need to use visualization and localization techniques, such as x-ray.

5. Consider E/M-25 Under These Circumstances

Although surgical codes " even minor ones " include some evaluation and management of the patient, you can report an office visit (99201-99215, Office or Other Outpatient Services) in addition to FBR provided documentation meets the criteria for modifier 25 (Significant and separately identifiable evaluation and management service provided by the same physician on the same day of the procedure or other service). You're more likely to add an E/M-25 with an FBR if the patient doesn't know what's causing pain or discomfort in an area.

Example: A patient comes in complaining of a hand wound that won't heal. The internist inspects the cut and on palpitation feels a foreign body may be under the skin preventing the wound from closing. The internist uses a scalpel to open the laceration further and pulls out a piece of glass.

Since the internist in this scenario had to evaluate the injury prior to identifying and removing the foreign body, you could report an E/M-25 service in addition to the FBR. Documentation should show separate notes for the E/M service leading to the physician's finding of an FBR and his decision to remove it. The procedure should then be described in a paragraph separate from the E/M note. The claim would include 99201-99215 for the office visit appended with modifier 25. Code the FBR as 10120. ICD-9 coding includes 914.6 (Superficial injury of hand(s) except finger(s) alone; superficial foreign body [splinter] without major open wound and without mention of infection).