ED Coding and Reimbursement Alert

Question: A patient with a tick embedded in his right thigh reports to the ED. The physician performs a standard E/M, then uses a pair of tweezers to pull the tick out. Parts of the tick's mouth, however, are still in the patient's thigh. The physician then makes a small incision and uses an 18-gauge needle to scrape out the remaining parts. Is this a foreign body removal (FBR) or an E/M service? Indiana Subscriber Answer: Both. Provided your documentation is solid, you can code for the FBR and the E/M. Go back and check the documentation to ensure that the physician provided all the components on an E/M in addition to removing the tick via incision. If you can support an E/M and an FBR with the notes, report the following: - 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the incision and needle scraping portions of the procedure - the appropriate-level E/M code based on encounter notes, such as 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision making of low complexity), for the initial tick removal attempt - 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 the E/M to show it was separate from the FBR - 890.0 (Open wound of hip and thigh; without mention of complication) appended to 10120 and the E/M to represent the patient's injury. Important note: CPT stipulates that you must make an incision to report 10120. Therefore, if the physician removed the tick without making an incision, you would report only an E/M (remember to roll the tick removal work into the overall E/M level in these cases).