Primary Care Coding Alert

Question: A primary care provider in our practice removed a piece of popcorn kernel from a patient’s tonsils. What are the best CPT^® /ICD-10 codes to use in this encounter?

New York Subscriber

Answer: Documenting the procedure in this situation is fairly easy. The most likely code you’ll use will be 42809 (Removal of foreign body from pharynx).

If documentation supports billing separately, you can also code an evaluation and management (E/M) visit from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …), 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 code. Providing the physician has documented that the E/M led to the decision to perform the foreign body removal (FBR), the modifier will let your payer know that the two services were separate and significant.

For the diagnosis, you will have to use one, or maybe two, ICD-10 codes to describe the patient’s condition. Assuming your provider did not document that the patient was asphyxiating, the first code you would use would be T17.228A (Food in pharynx causing other injury, initial encounter). Next, as this is an initial encounter, and depending on payer or state guidelines, you may want — or may have — to add a code to indicate the place of occurrence. You will find the appropriate code located in the Y92.- (Place of occurrence of the external cause …) codes.