Otolaryngology Coding Alert

Hint: It’s not always just about location and depth.

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 Made or a Scope Used?

In many specialties, you cannot report an FBR if the physician can remove the foreign body without making an incision. That’s not always the case with otolaryngology, however, so pay attention to the procedure and your physician’s documentation.

Example 1: The physician uses a probe and other instruments to remove a foreign body from the patient’s ear. He doesn’t make an incision or use a scope, but you can still submit FBR code 69200 (Removal foreign body from external auditory canal; without general anesthesia) because it accurately describes the procedure. 

If your ENT can remove the foreign body without making an incision or using a scope, you might only report the appropriate E/M code or a procedure code that doesn’t indicate FBR.

Example 2: The physician uses tweezers to remove a splinter from a patient’s neck, applies antibiotics, and dresses the wound. In the strictest sense, the physician did remove a foreign body, but he didn’t make an incision and the documentation doesn’t necessarily justify a FBR code. The appropriate E/M code (such as 99212, Office or other outpatient visit for the evaluation and management of an established patient ...) might be the best choice.

Note: CPT^® includes specific FBR codes for many anatomic sites, but not all. The neck is one of these areas. If you’re able to report FBR but don’t have a specific code for the body area, use 20520 (Removal of foreign body in muscle or tendon sheath; simple) or 20525 (... deep or complicated), depending on the depth of incision necessary.

2. Was the FBR Incidental?

You should not report FBR if the physician discovers and removes a foreign body during wound exploration, says Linda Martien, CPC, CPC-H, coding specialist with National Healing in Boca Raton, Fla. 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. For example, if a pebble is removed from a child’s nasal cavity while the doctor is controlling an epistaxis, you should only report the control of the epistaxis via endoscopy with a code such as 31238, (Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage).

3. How Deep Was the Object?

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’ll need to read deeper into the documentation.

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. Some codes are broken into simple and complicated. These may or may not refer to the depth of the foreign body. They may be related to the complexity and time involved in removing the FB.

Example: A patient may have an embedded foreign body in the vestibule of the mouth.  Code 40805 (Removal of embedded foreign body, vestibule of mouth; complicated) represents complicated removal using local anesthesia. The physician makes an incision to where the foreign body is embedded. The physician grasps the object with the help of forceps, and removes the object. He then applies some antiseptic or bandages to the incised area for healing. Report the complicated code if the procedure requires extended time or the given case is complex or complicated. The operative report should indicate the complexity involved.

4. Do You Need Modifiers?

The FBR codes stipulate “foreign body” in their descriptors as singular, not plural. Therefore, you should report each removal as a separate procedure. In addition, the code for foreign body removal from the ear is a unilateral code, so you need to bill any removals per ear.

Example: The otolaryngologist removes objects from each of a child’s ears under anesthesia. You’ll begin your claim with 69205 (Removal foreign body from external auditory canal; with general anesthesia). To indicate a separate site (left ear from right ear), append modifier 59 (Distinct procedural service) to the second ear procedure because the modifier 50 (Bilateral procedure) is not applicable to 69205 in the fee schedule.

Tip: You may also want to append modifier LT (Left side) and RT (Right side) to 69205 to identify the specific ear for clarity on the claim. For removing one bead from the right ear and one bead from the left ear, you might bill:

• 69205-RT
• 69205-59-LT.