Pediatric Coding Alert

Question: A 12-year-old established male patient presents to the pediatrician with complaints of a swollen foot. He had been running barefoot at a picnic three days earlier, but didn’t experience any discomfort until yesterday, when his foot “started hurting really bad.” He reports a 6 out of 10 on the pain scale. During an evaluation and management (E/M) service, the clinician notes that the patient’s heel is swollen and leaking pus. Upon examination, the clinician reports finding a foreign body (FB) in the patient’s heel; notes indicate it was most likely a wood splinter. The clinician is unable to remove the FB with only tweezers, so he uses a scalpel to make an incision, removes the FB with tweezers from the patient’s subcutaneous tissue, dresses the wound, and sends the patient home. How should I report this encounter?

North Dakota Subscriber

Answer: You’ll report a code for the foot foreign body removal (FBR) and, most likely, an E/M code for the service that preceded the FBR.

On the claim, you would report 28190 (Removal of foreign body, foot; subcutaneous) for the FBR.

Then — provided you can prove that the clinician performed a significant, separately identifiable E/M prior to the FBR — you would report a code from the 99212 (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 problem focused history; a problem focused examination; straightforward medical decision making …) through 99215 (… a comprehensive history; a comprehensive examination; medical decision making of high complexity …) code set, depending on encounter specifics.

Remember: If you do report a separate E/M, be sure to append 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 to show that the FBR and the E/M were separately identifiable services.

Since it appears your clinician performed a separate FBR before arriving at the 28190 decision, a separate E/M is possible. If you are unsure about the pre-FBR E/M, check with the clinician to see if there is enough work to warrant a separate E/M service. Also remember that you must document the procedure properly: this should include an explanation to the patient/caregiver about the separate E/M; information on how the provider performed the E/M, the results of the initial FBR attempt, etc. This documentation should not be in the body of the examination notes; separate the E/M explanation to demonstrate that the visit was required in order to determine the need for the procedure (FBR with incision).