Pediatric Coding Alert

See if your solution makes the cut.

Active kids seem to be magnets for foreign bodies, which is why foreign body removals (FBRs) are so commonplace in pediatric medicine. But coding them isn’t as straightforward as you think.

That’s because there are three different possible ways to code and bill for an FBR, as the case study below shows. Follow along and see if you know the different ways to code FBR encounters.

The Case

An established patient reports to your office with a splinter embedded in the sole of her foot after running around deck. Your pediatrician removes the splinter at the encounter.

Evaluate This First FBR Solution

As this case study does not provide details regarding the method your pediatrician used to remove the splinter, the first problem you have to solve before coding this encounter correctly is determining how the pediatrician removed the foreign body.

The key word here is “incision.” If the pediatrician does not make an incision into the patient’s foot, and instead removes the splinter “using tweezers or another implement, it would be considered part of an evaluation and management [E/M] visit. So, you should roll the work of the removal into the E/M,” suggests Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America.

In this case, the patient’s complaint can be regarded as an acute, uncomplicated illness, defined by CPT^® as “a recent or new short-term problem with low risk of morbidity for which treatment is considered,” and for which “there is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.” Additionally, the FBR itself presents a low risk of morbidity to the patient. These two low elements of medical decision making (MDM) combine to give an overall low MDM, enabling you to easily justify billing 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) for the visit.

Know What to Do if Removal Methods Change

“After using certain tools without success or after trying for a period of time, an incision might be the best approach. All of this should be detailed within the medical record,” Hauptman suggests. In this case, you may be able to claim both the E/M and the incision service by coding for both, attaching modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M.

Be Incisive With This Second Solution

If the FBR turns from an E/M to a removal by incision, or if your pediatrician immediately uses a scalpel or other sharp instrument to cut into the patient’s skin to find and remove the foreign body in the encounter, two procedure codes may then come into play: 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (… complicated).

To determine which of the two you should use, you need to understand the difference between simple and complicated FBRs.

CPT^® does not offer a definition of “complicated.” Instead, factors such as “infection, scarring in the area, multiple foreign bodies, or delayed treatment,” may complicate the FBR removal, Bucknam explains. Removals involving exploration or debridement of the wound could also rise to the complicated level.

When that happens, you should leave the determination of the procedure’s complexity to your pediatrician — simply put, if your pediatrician has used the term “complicated” in the documentation, you can go with 10121.

And Don’t Remove This Site-Specific Third Solution

The musculoskeletal surgery codes (20100-29999) also contain numerous FBR codes specific to various anatomic areas, including 28190 (Removal of foreign body, foot; subcutaneous), 28192 (... deep) and 28193 (... complicated). Using these codes instead of 10120-10121 in the pediatric setting is unlikely, as 28190-28193 require much more work, including local anesthesia, irrigation, and even wound closure with strips or sutures when appropriate. But it is not impossible that your pediatrician may have to go to these lengths to remove the splinter “if the foreign body is deeper, or if it involves the fascia,” says Bucknam.