Part B Insider (Multispecialty) Coding Alert

You can't report multiple FBR codes, but you still may be able to recoup extra when your physician removes more than one foreign body

If you report a foreign body removal (FBR) code even when the physician doesn't make a separate incision, you're not alone--but you're also not coding correctly.

Although coding for a FBR can vary greatly based on anatomical location and depth of the foreign body (FB), there are a few rules you can't afford not to know. Test your knowledge against these five professional Q&As:

1. Question: Should the instrument used determine which code I choose when the doctor performs a FBR in the cornea or conjunctiva of a patient's eye?

Answer: No. You'll need to use code series 65205-65222 for this scenario, and these codes do not indicate any particular instrument for removing the FB. You should choose a code according to the specific location and level of penetration of the FB in the eye. For example, for the removal of a superficially-penetrating FB in the conjunctiva, you would report 65205 (Removal of foreign body, external eye; conjunctival superficial). The physician may use a cotton swab, needle, burr or other instrument, but this does not affect code choice.

Not so fast: If your physician performs an FBR in the cornea, you will need to consider the method involved: whether he uses a slit lamp to visualize the FB. Report 65220 (Removal of foreign body, external eye; corneal, without slit lamp) if the physician did not use the slit lamp; otherwise, report 65222 (EM>with slit lamp).

In addition, you have to consider whether the physician uses a magnetic (65260) or nonmagnetic 65265) extraction method if you're dealing with a FBR in the posterior segment of the inner eye, points out Linda Martein, CPC, CPC-H, coding specialist with National Healing in Boca Raton, FL.

Method can matter: In addition to the examples above, there are other times when the FBR method will dictate your code choice. For example, suppose a mentally-handicapped patient has accidentally swallowed a small battery. Your physician may use an endoscope to remove the foreign body from the patient's stomach. If so, you would report 43247 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body). However, if the physician is unable to remove the foreign body using an endoscope, he may make a small incision to perform the FBR, prompting you to report this different method with 43247 (Upper gastrointestinal endoscopy including esophagus, stomach ... with removal of foreign body).

2. Question: How should I code if my physician explores a wound but finds no foreign body to remove?

Answer: You shouldn't report an FBR code if the physician doesn't remove any FB from the patient's wound. An FBR code in that situation would not correctly describe the rendered service.

Example: A patient presents with a small knife wound in his leg and your physician explores the wound for debris and other FBs, but finds none. Because this is a penetrating wound (gunshot, knife and dog-bite wounds fit in this category), you should report 20103 (Exploration of penetrating wound [separate procedure]; extremity). Note: Even if the provider had removed an FB during wound exploration, you could not report it separately because the wound exploration codes include FBR services.

3. Question: What is the rule for determining whether a splinter or tick removal counts as an FBR?

Answer: If the physician makes no separate incision as part of the FBR, then you cannot report an FBR code, Martein says. Instead, you should count the FBR service toward the overall E/M level you report for the visit. So for example, if your physician removes a large splinter from a patient's arm without making a separate incision, you might report 99213 (Office or other outpatient visit for the evaluation and management of an established patient to bill for the exam, decision making, FBR and any counseling afterward.

The same holds true for the removal of ticks, a procedure that usually doesn't require an incision. Remember, if the tick or splinter removal doesn't necessitate a separate incision, you should simply include the service in the appropriate-level E/M code.

In the case of incision: When a tick or splinter removal does require an incision, choose an incision and removal code based on location of the FB and the extent of the incision. For example, if your physician makes an incision to facilitate an FBR in a patient's shoulder, you would choose between 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) and 23330 (Removal of foreign body, shoulder; subcutaneous), depending on the extent of the FB and incision. If the physician has to make an incision that extends past the subcutaneous tissue into the fascia or muscle, 23330 would be the appropriate choice, Martein says.

Closure included: The Centers for Medicare & Medicaid Services considers a simple repair included in 10120, so be careful not to report a separate closure code, such as 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less). The only way you can code separately for a closure is if the provider performs an intermediate or complex repair (code sets 12031-12057 and 13100-13160, respectively), Martein says. Note: Code 23330 includes any closure level the physician performs.

4. Question: What criteria should I consider to help me choose between a simple or complicated FBR in the skin?

Answer: Your physician's documentation should dictate the code you choose, and if she has specifically stated the FBR was simple,then you must report 10120 for a simple incision and removal of a FB, Martein says.

However, if the physician does not explicitly state that the FBR was simple or complicated, you will have to read deeper into the documentation. Warning: Coders commonly over-bill for this service, says Cheryl Odquist, CPC, a reimbursement and compliance consultant with Codeology in San Diego, CA--so think carefully before reporting a complicated FBR.

Clues to complicated: Report 10121 (complicated) if the documentation mentions specific exploration, extensive cleansing/debridement or extension of the wound, Martein advises. And don't hesitate to ask your physician if you suspect she determines simple or complicated FBR using different criteria.

Bright idea: Institute a policy on what criteria must be present in order for a FBR to qualify as complicated, Martein suggests. A written policy will safeguard you in the event of an audit, making your coding defensible as long as you coded according to the written policy, she says.

5. Question: If my physician removes several foreign bodies from the same site on a patient, can I report multiple FBR codes to bill for the extra work?

Answer: FBR codes generally do not specify each in the descriptor, meaning that you should not report them for each FB your physician removes. Instead, you should only report one FBR code per anatomical site, regardless of how many FBs are involved, Martein says.

This policy can seem unfair when the physician clearly performs more work to remove many FBs. In the case of a shrapnel wound, the provider may have to spend over an hour removing various FBs from the wound site. But while you can only report one FBR code for this service, remember that you may also be able to report an appropriate E/M code to account for the assessment and medical decision making the physician performed before starting the FBR, Martein says. You'll need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code in order to recoup payment for both the E/M and the FBR, she notes.

Another option: You could also consider appending modifier 22 (Unusual procedural services) to the FBR code to recoup for the extra work. To do this, you'll need to submit a thoroughly-documented operative report, a good explanation of the more extensive service and a fair charge for the extra work.