AAPC - credentialing the business side of medicine

rhblevins61@yahoo.com · #1 06-13-2011, 12:13 PM

Need other opinions on CPT(s). Not sure if this procedure is included with the E/M since it is a removal of foreign body?

Procedure reads: Area was anesthetized with one percent lidocaine plain digital and local block. Could not push the barb forward due to the other hooks. The barb was pulled back through the skin over the barb was nicked with number 11 scalpel and the hook came loose. No problems or complications. Tetanus shot was given.

Thanks for any help.

nkawtgn · #2 06-13-2011, 03:08 PM

I don't think that an E&M code is appropriate. You would use site specific removal of foreign body codes.

NaliniAAPC · #3 06-13-2011, 03:22 PM

Hi,
I too thinking the same...Code only the procedure of removal foreign body..

Nalini CPC

PeaPod1 · #4 06-14-2011, 09:55 AM

My understanding is that you cannot code a removal of FB w/o incision and the referenced note does not clearly indicate an incision... I code quite a few of these in our ER(the Land of 10,000 Lakes and at least 10 fish hooks in the hand on any summer weekend

and include the procedure in the E/M if an incision is not clearly documented.
Have a great day.

kjohnson · #5 06-20-2011, 10:48 AM

I agree with PeaPod, if there is no documentation of an incision, we can't code the foreign body removal. We capture the time spend in the E&M level.

Jane F. Elliott CPC CPMA · #6 06-28-2011, 02:20 PM

yes - doc used an #11 scalpel, this is an incision

PeaPod1 · #7 06-28-2011, 03:50 PM

I would not have coded as a procedure because I didn't interpret "barb was nicked" as enough documentation to support an incision into the skin... It could be read and interpreted without further inquiry to mean he simply nicked the actual barb on the hook with the scalpel and made it easier to pull out??

Definitely one that would need clarification from the performing provider.

Jane F. Elliott CPC CPMA · #8 06-29-2011, 01:08 PM

fish hooks has barb on them - if you didn't cut the skin it would do more damage - can you give me info on documentation for an incision.

Mojo · #9 06-29-2011, 06:14 PM

If the procedure note was posted exactly as documented, I would have asked for clarification on what was nicked. An instrument was noted so that tells me something was incised/cut. A simple, "Skin over the barb was nicked with a #11 scalpel..." would suffice.