ED Coding and Reimbursement Alert

Ah, spring. The birds, the bees - and more soft-tissue foreign body removals (FBRs) for EDs.

Remember, the physician removing a foreign body does not necessarily mean you can report an FBR code. Be ready for the splinters, ticks and other FBs that your ED physician might see with this advice on soft-tissue FBRs.

The rule on soft-tissue FBRs is cut and dried: if the provider does not make an incision during the service, then you cannot code 10120 (Incision and removal of foreign body, subcutaneous tissues; simple), confirms Gerri Walk, RHIA, CCS-P, senior manager at Health Record Services Corporation in Baltimore.

Example: A guy walks into the ED with a splinter in his left ring finger. A nonphysician practitioner (NPP) examines the injured area, pulls the splinter out with tweezers, bandages the patient's finger, and discharges him.

This is not a soft-tissue FBR, for coding purposes. It is a low-level E/M, such as a 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a problem focused history; a problem focused examination; and straightforward medical decision making ...).

Warning: If you report 10120 for this kind of encounter, you're playing with fire, as auditors will view it as fraud. "An incision is definitely required [for 10120], as opposed to removing the FB with tweezers only," Walk explains.

Example: A patient reports to the ED with a tick embedded in the back of his right knee. The NPP examines the wound, and makes an attempt to remove the tick with tweezers without success. The ED physician then uses a scalpel to cut a slit on the patient's skin just below the tick. He then removes the tick using tweezers.

This is an FBR scenario; on the claim, you'd report 10120 for the removal.

While the ED might not see too many complicated FBRs, your ED will occasionally perform complex soft-tissue FBRs, which you'll code with 10121 (... complicated).

Payout: Spotting legitimate 10121 encounters will net you about twice as much money as a 10120 claim. The code pays about $174 per encounter (4.80 transitioned facility relative value units [RVUs] multiplied by the temporary 2010 Medicare conversion rate of 36.0846); 10120 brings in about $85 per encounter (2.38 RVUs multiplied by 36.0846).

A 10121 situation typically surfaces "when the FB is embedded deep within the subcutaneous tissue. This FBR may require dissection of underlying tissue," says Pamela Cline, RHIT, senior coding supervisor for Medical Account Services in Frederick, Md.

Use this: Walk recommends using the definition of complicated soft-tissue FBR in Coder's Desk Reference as a guide. The reference defines a complicated removal as "involving dissection of underlying tissue to get at the foreign body, without going into the muscle," Walk explains.

While most of your soft-tissue FBR encounters will include a separate E/M service, think twice before choosing a higher-level E/M code, Walk says.

You can code for a separate E/M with the FBR codes, but the physical exam must involve more body areas than where the FB was located. "Medical necessity comes into play also; no carrier will pay for a level-three visit for a finger splinter no matter how much of an exam is documented, " according to Walk.

Best bet: If you're considering a mid- to high-level ED E/M code along with 10120, be sure to review the notes to see that the E/M code is on target.