Primary Care Coding Alert

Here's why you-ll use E/M codes for some foreign-body removal encounters

Patients who report to your FP for foreign-body removal (FBR) present a challenge for coders. And with the summer months fast approaching, more outdoor work and play for your patients could mean a rush of FBRs for your FP.

When your FP removes a foreign body from a patient's skin, including subcutaneous or accessory structures, you-ll typically code either 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (... complicated) for the encounter, depending on specifics.

But in order to code your FBR encounters properly, you-ll need to know the difference between a simple and complicated FBR. Further, coders also need to know when a removal does not meet the clinical definition of FBR, because you-ll code these scenarios with an evaluation and management code instead.

Code Most Simple Splinter Removals With 10120

While the 10120 descriptor contains the term -simple,- CPT gives you no exact definition of a simple FBR, says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan. -It is a matter of interpretation,- he says, and offices have to decide for themselves what constitutes simple FBR.

Freda Fontaine, director of coding/compliance for Plano, Texas-based Questcare Practice Management, considers an FBR to be simple when:

• the FP removes the FBR via simple incision overlying a foreign body embedded in subcutaneous tissue.
• the FBR requires minimal debridement and no dissection.

Consider this example from Fontaine: A 34-year-old established female patient fell from a ladder while hanging a mirror. She presents complaining of arm and finger pain, multiple contusions of the upper arm and shoulder, and a glass splinter embedded beneath the skin on the right index finger. After taking an expanded problem-focused exam and an expanded problem-focused history, the FP makes a single incision over the FB site, permitting removal of the glass with splinter forceps. The area is then cleaned and secured with steri-strips.

In this instance, the FP made a single incision and was able to close the FBR site without incident. This qualifies as a simple FBR. On the claim,

• report 10120 for the FBR.
• report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity) for the E/M service.
• 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 99213 to show that it was a separate service from the FBR.
• link 923.09 (Contusion of upper limb; shoulder and upper arm; multiple sites) and 915.6 (Superficial injury of finger[s]; superficial foreign body [splinter] without major open wound and without mention of infection) to 10120 and 99213 to prove medical necessity for the encounter.
• link E881.0 (Fall from ladder) to 10120 and 99213 to represent the cause of the patient's injury.

Note: In this scenario, the FP provided FBR and a separate E/M service, but not all FBR claims will include an E/M code. -If the FB removal was the sole reason for the visit, insurance companies will generally consider the E/M bundled into the procedure,- Fontaine says.

Fontaine says that these are some other injuries your FP might encounter that require simple FBR:

• Patient has pencil lead embedded in subcutaneous skin of hand; FP cannot remove lead via deroofing.
• Patient has BB pellet lodged slightly beneath skin.
• Patient has splinter lodged in subcutaneous skin requiring single incision for removal.

Multiple Incisions Might Mean a Complex FBR

As with simple FBRs, CPT does not give a standard definition for complex FBR, Moore says. But there are certain actions the physician would take during a complex FBR that he would not take during a simple FBR.

Complex FBRs involve a more complicated process for removal, depending on the location and depth of the object, Fontaine says. Whereas simple removals typically consist of a single incision over the FB site and an uncomplicated removal, complex removals may include -extended exploration around the wound site, extensive dissection to free the FB, multiple incisions, or a combination of these efforts,- Fontaine says.

During a complex FBR, the FP may also need to use visualization and localization techniques. -Embedded FBs produce a granuloma formation around the object, making it difficult to detect by the human eye. In these situations, ultrasound, x-rays, CT scans, and radiographic guidance may be used for identification,- Fontaine says.

A patient reports complaining of pain after manually removing a fish hook from his left hand the day before. He has extreme sensitivity around the removal site, and a slight horizontal protrusion just below the skin's surface.

The FP makes two vertical incisions (one on each side of the FB), revealing the curved tip of the fishing hook embedded within the subcutaneous tissue. The FP performs underlying dissection of the tissue to dislodge the embedded portion of the hook and explores the wound for additional contamination (there is none). The FP then sutures the wound site and sends the patient home.

In this instance, the physician performed multiple incisions and wound dissection, meaning this is a complex FBR. On the claim,

• report 10121 for the FBR.
• link 914.6 (Superficial injury of hand[s] except finger[s] alone; superficial foreign body [splinter] without major open wound and without mention of infection) to 10121 to prove medical necessity for the encounter.

Fontaine reports that these FP scenarios might also constitute a complex FBR: Patient has jagged splinter FBR requiring moderate exploration and debridement, and patient has glass particles in finger requiring moderate exploration and vertical incisions for removal.

E/M Also an Option on Some FBR Claims

Coders, beware: When the FP removes a foreign body from a patient, it does not automatically mean you should report the encounter with an FBR code. In order to report an FBR code, the encounter must meet CPT's definition of FBR. Otherwise, you-ll report the appropriate E/M code, Moore says.

Incision is a must: The descriptors for CPT codes 10120 and 10121 both contain the word -incision,- so you must be sure the FP makes an incision before reporting one of these codes. If the operative notes indicate the FP performed -stroking to deroof the area and removal with needle tip or splinter forceps,- the encounter is likely not an FBR, Fontaine says.

For example, a patient reports with a splinter in his right hand. The FP strokes the injured area, then removes the splinter with forceps. In this instance, you-d report an E/M code instead of an FBR code.