Podiatry Coding & Billing Alert

Wound care or FBR? Choose wisely.

A patient had a wood splinter lodged in the foot which needed removal, requiring wound care subsequently. If you’re confused as to what should be the initial code — the foreign body removal (FBR) or the wound care; then we have expert advice for you.

First Read This Case Study

Take this example of a podiatrist’s notes: A 43-year-old new patient comes to the office with the chief complaint of a painful left foot that has been present for 3 days. He has a history of well controlled diabetes type II, with no other known medical problems. There are no known allergies and the only medication being taken is Metformin 1000 mg twice daily. Vascular exam is WNL with mild peripheral neuropathy noted.

On inspection of the left foot, the left ball of the foot was found to be red and swollen on the plantar surface under the 2^nd and 3^rd metatarsal head with a small black dot in the center of the redness. You are not able to touch the area due to a pain level of 7. So, after obtaining consent, it is prepped with betadine and then 1 cc of 2% lidocaine is injected for anesthetic. A small incision is made and some clear fluid drained and cultured. The area is explored and a 5 mm wood splinter is removed from the subcutaneous tissue. The area is lavaged with saline and covered with an antibiotic dressing and the patient placed on an oral antibiotic.

Assess What Physician is Really Doing

“Wound care might be needed ... but that’s after foreign body removal (FBR),” says Apoorba Ganguly CPC, CPMA, Manager of Coding Department for Medfin Billing Services Pvt. Ltd., Kolkata, India. “A puncture wound of foot is to be coded with 28190 (Removal of foreign body, foot; subcutaneous). If the removal takes place from deep tissue layer of foot/heel, the code is 28192 (Removal of foreign body, foot; deep).”

You should not report codes like 10120 (Incision and removal of foreign body, subcutaneous tissues; simple)/10121 (Incision and removal of foreign body, subcutaneous tissues; complicated), if the fascia was penetrated and the foreign body was within the fascia, subfascial, or muscle.

CPT^® FBR codes for the foot and toes are classified as follows: 28190, 28192, and 28193 (Removal of foreign body, foot; complicated). The depth of the incision required for the FBR will be key in determining which procedure to report.

Determine FBR code appropriateness: To determine whether an FBR code is appropriate and which one to use, you should review the operative report for answers to four questions:

1. Did the podiatrist have to make an incision to remove the object?
2. Was the surgery performed to remove the foreign body, or did the podiatrist discover it while doing something else?
3. Where was the object?
4. How deep was the foreign body embedded?

The FBR codes in the musculoskeletal chapter of CPT^® involve an incision going beyond the skin level. You need an incision to get that deep before reporting 28190 or 28193.

Knowing what procedures your podiatrist carried out, your CPT^® code for active wound care management should be 97597 (Debridement [e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application[s], wound assessment, use of a whirlpool, when performed and instruction[s] for ongoing care, per session, total wound[s] surface area; first 20 sq. cm or less).

In addition, you will code the anesthetic injection with the HCPCS code J2001 (Injection, lidocaine HCl for intravenous infusion, 10 mg). Check with your physician whether the antibiotic topical application was from his own medication. You will need additions to the notes to indicate which antibiotic to code and bill it accordingly.

Break Down Diagnosis Codes

“As the diagnosis code, if the FB is lodged only superficially without causing an open wound, code S90.851 (Superficial foreign body, right foot), S90.852 (Superficial foreign body, left foot) or S90.859 (Superficial foreign body, unspecified foot) based upon the information on laterality,” says Ganguly.

“If an open wound took place, S91.33- (Puncture wound without foreign body of foot) or S91.34- (Puncture wound with foreign body of foot) would be the code with the 6^th digit based on laterality,” Ganguly adds.

Don’t Miss The Opportunity to Report E/M Codes

To be able to report any E/M code (99201-99215, Office or other outpatient visit …) with the FBR, remember the documentation should also support Z87.821 (Personal history of retained foreign body fully removed) or Z87.828 (Personal history of other [healed] physical injury and trauma). Additionally, you must use Z18.- (… retained foreign body fragments) or Z87.821 to indicate current status of foreign body.

While coding for the encounter, don’t forget the exclusions in your excitement. Z18 has an Exclusions 1 list indicating two conditions which can’t occur together. The vital points of this list are Z96.6- (Presence of orthopedic joint implants), T81.5- (Complications of foreign body accidentally left in body following a procedure) and Z87.821.

Finally, Check Out What Will Be New in October 1

Come Oct. 1, you will need to also consider some of the new codes. Now that the new code freeze period is ending, the Centers for Medicare & Medicaid Services (CMS) has decided to add 1,900 new diagnosis codes, revise 422 codes, and delete 305 codes.

Code Z18 is already supposed to describe the current status of a foreign body, such as whether there is a fragment or splinter embedded within a bodily area or whether it is retained from a previous procedure. Given the massive degree of specificity which ICD-10 demands, the new additions to Z18 include:

• Z18.0 — Retained radioactive fragments
• Z18.01 — Retained depleted uranium fragments
• Z18.09 — Other retained radioactive fragments
• Z18.1 — Retained metal fragments
• Z18.10 — Retained metal fragments, unspecified
• Z18.11 — Retained magnetic metal fragments
• Z18.12 — Retained nonmagnetic metal fragments
• Z18.2 — Retained plastic fragments
• Z18.3 — Retained organic fragments
• Z18.31 — Retained animal quills or spines
• Z18.32 — Retained tooth
• Z18.33 — Retained wood fragments
• Z18.39 — Other retained organic fragments
• Z18.8 — Other specified retained foreign body
• Z18.81 — Retained glass fragments
• Z18.83 — Retained stone or crystalline fragments
• Z18.89 — Other specified retained foreign body fragments
• Z18.9 — Retained foreign body fragments, unspecified material

Resources: For more on ICD-10 code additions, revisions, and deletions, please check: https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-PCS-and-GEMs.html.