Pediatric Coding Alert

Time to find out the depth of your foreign body removal knowledge.

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below:

Answer 1: The first, and most important, rule of foreign body removal (FBR) coding is to look for evidence that your pediatrician has made an incision into the patient’s skin in order to remove the foreign body. If there is no incision, and “if the physician can just take forceps and grasp the foreign body and pull it out, then there is no separate coding for the service,” says Marcella Bucknam,CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

In other words, “if the physician uses 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, counting it toward a detailed examination, perhaps part of the 1997 integumentary examination, if all other elements are present,” notes Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. This would enable you to document 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity …) or 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …) depending on the patient’s status and, again, providing the other key components for the service are met.

Coding alert 1: In these FBR situations, your pediatrician should make a decision about how much effort should be spent trying to remove the foreign body before deciding to remove it via an incision. “The physician should set a limit on these types of removal; it could be a time limit or an implement limit. 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.

Once that limit is reached, and the pediatrician makes the decision to remove the FBR using an incision, 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.

Answer 2: In this situation, because your pediatrician has made the incision into the patient’s forearm, you can now go ahead and code 10120 (Incision and removal of foreign body, subcutaneous tissues; simple).

Coding alert 2: Though such encounters may be rare in pediatric practices, “it’s worth noting that if the foreign body is deeper, or if it involves the fascia, this should be coded in the musculoskeletal system section of CPT^®,” says Bucknam. In this particular example, that would mean coding 25248 (Exploration with removal of deep foreign body, forearm or wrist).

Answer 3: In this situation, you would report 10121 (Incision and removal of foreign body, subcutaneous tissues; complicated). While CPT^® does not offer a definition of “complicated,” such factors as “infection, scarring in the area, multiple foreign bodies, or delayed treatment,” may complicate the FBR removal, Bucknam explains. When that happens, you should leave the determination of the procedure’s complexity to your pediatrician, but you should make sure that your pediatrician has used the term “complicated” in the documentation.