Wiki Removal of metallic foreign body w fluoro

[mgord]

Can someon please tell me if they would initially code this as simple or complicated, 20520 or 20525?
pt inadvertently injured by pellet gun attempts to remove in the ER were unsuccessful so pt was taken to the OR a week later

site of the FB identified by fluoroscopy. incision made over that site which was about 6 cm from the entry wound. Using blunt dissection with a hemostat the FB was approached. The musuclar tissue in which it was imbedded was retracted to enable further immobilization of the FB which was then finally grasped with a hemostat and removed intact. Cultures were obtained of the FB. Wound irrigated with saline. The field was imaged once again and no remnance of FB found. No bleeding. Wound was closed with a 4-O Monocryl to approximate the subQ tissue and then the six margin was approximated with 4-O Monocryl subcuticular closure. Mastisol and Steri strips were applied to the skin margins as well as dry sterile occlusive dressing.

The metallic FB actually was about 6-7 cm from the entry wound and appeared to be imbedded in muscular tissue.

I coded this as 20520 and 76000 for the MD. However when the facility was denied they contacted me and said they had coded the same thing but were wondering if 20525 would be more appropriate. I queried the MD who became very upset wondering why I would have ever thought this was simple. He even went to my manager asking her opinion and she is not even certified coder!
Does anyone think this was coded incorrectly? Or any thoughts would be greatly appreciated.
Thanks!!

 

[FTessaBartels]

Did he title the op note

For 20525 I will be looking for certain key phrases to tell me this is warranted ... "deep" or "complicated" or evidence that the wound was "dirty" or required "packing."

I ask my surgeons to "title" their op notes for FB removal so that I specifically know what it is THEY are thinking ... is is "deep" ... is it "complicated" ... do you have a "contaminated wound" or did they need "gauze packing"

It seems this was pretty straightforward, but I can't tell if your statement that it was 6-7 cm from entry and imbedded in tissue is actually part of the surgeon's dictation or just what you learned after you queried the physician.

Not seeing any of the key phrases/words in the dictation, I would have coded it as 20520.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[mgord]

6-7 cm from entry and imbedded in the tissue was part of the dictation under operative findings - the surgeon told me that based on these statements, I should have deduced that it was complicated and no surgery that any of our doctors perform is ever simple