EM Coding Alert

Question: A patient reports to the physician’s office with a jagged piece of wood in his left palm. The physician removes the wood using a pair of tweezers. Is this an evaluation and management (E/M) service or a procedure?

Iowa Subscriber

Answer: The procedure you describe is a foreign body removal (FBR), but that doesn’t necessarily mean that you’ll be able to choose an FBR procedure code.

The answer depends on whether or not the physician made an incision in order to remove the wood from the patient’s palm. Go back and take a look at the notes. If the notes indicate that the physician made an incision during the encounter, then you’d choose 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (… complicated) for the procedure.

When you cannot find evidence of an incision, you’ll choose the appropriate-level E/M code based on encounter specifics:

• 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making) to 99205 (… a comprehensive history; a comprehensive examination; medical decision making of high complexity) for new patients; and
• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) to 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity) for established patients.

Complicated FBR unlikely: For in-office FBRs, you’ll almost always choose an E/M code for the service or 10120. Complicated FBRs are very rare in an office setting. If, however, the physician used any of the below techniques during treatment, you might have a 10121 encounter:

• Physician conducted x-rays
• Physician conducted fluoroscopy or ultrasound
• Physician conducted debridement
• Physician performed extensive cleaning or irrigation
• Physician removed multiple foreign bodies (gravel, wood splinters, etc.).