Primary Care Coding Alert

Youve nailed down a charts soft-tissue foreign body removal (FBR) support, and you can also justify an office visit when you see these items.

Look for Evaluation, Removal Decision

If the patient reports with a possible FB, and the physician has to evaluate the site and make a decision to attempt to remove the FB, you might be able to report 10120 and an E/M, says Kevin Solinsky, CPC, CPC-I, CPC-ED, president and CEO of Healthcare Coding Consultants LLC in Gilbert, Ariz.

Think 25 on New, Maybe on Established

There must be a separate, identifiable service in addition to the assessment and removal of the FB, says Linda Martien, CPC, CPC-H, coding specialist at National Healing Inc. in Boca Raton, Fla. If an FBR patient is new, the FP usually provides an E/M-25 in addition to the FBR.

The FP might also provide a separate E/M-25 to established patients, says Martien.

Example: An established 35-year-old patient comes in after a bicycle accident; the patient has debris in her right forearm and pavement burn. The nonphysician practitioner (NPP) cleans the wound, and the FP examines the forearm abrasions. The FP removes several bits of gravel with pickup forceps and tweezers.

Further examination reveals larger embedded pieces of gravel and road debris. The FP numbs the area with topical lidocaine gel and manipulates the forearm, causing the patient to wince in pain. The FP orders an x-ray, which shows a small hairline fracture of the right distal ulna.

The FP uses a #15 scalpel to excise the larger pieces of debris and gravel, and the NPP irrigates and bandages the wound. The FP places the forearm in a static splint without placing any sutures. Notes indicate an expanded focused history and exam and low-complexity medical decision making.

In this scenario, report the following:

" 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the E/M

" Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99213 to show that the E/M and excision were separate services

" 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the FBR

" 73090 (Radiologic examination; forearm, 2 views) for the x-ray with modifier RT (Right side) appended

" 29125 (Application of short arm splint [forearm to hand]; static) for application of the splint

" If the insurer allows it, you may also want to report the appropriate HCPCS level-II code or CPTs generic 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered &) for the splint.