Internal Medicine Coding Alert

You Be the Coder:

Depth and Location Important To Report FBR

Published on Mon Dec 28, 2015

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Question: Our internist performed a minor surgery on a patient to remove a wooden splinter from his left foot. I am seeing many different codes for foreign body removal. I am confused about what code I need to report for the procedure that our physician performed.

Maryland Subscriber

Answer: The code that you will have to report depends on where the foreign body was located and the complexity of the procedure performed. Your physician’s documentation should dictate the code you choose (simple or deep/complicated). If your physician does not explicitly state that the foreign body removal (FBR) was simple or complicated, you’ll need to read deeper into the documentation to discern the right code.

If the foreign body is embedded above the fascia, you should call on the simple, superficial, or subcutaneous codes. If the object crosses the fascia, choose the “deep” codes. Some codes are broken into simple and complicated. These may or may not refer to the depth of the foreign body. They may be related to the complexity and time involved in removing the FB. Refer to your physician’s notes and expertise when choosing between “simple” and “complicated.”

For a foreign body removal from superficial subcutaneous tissues where no incision is made (e.g. the physician simply pulled the splinter from the foot with some tweezers), simply choose an appropriate evaluation and management code for the encounter.

For a foreign body removal from superficial subcutaneous tissues that involved an incision, you will have to choose from one of the following two codes:

10120 (Incision and removal of foreign body, subcutaneous tissues; simple)
10121 (…complicated)

If the fascia was penetrated and the foreign body is located within the fascia, subfascial, or muscle, then you will have to report one of the musculoskeletal series of codes. For example:

20520 (Removal of foreign body in muscle or tendon sheath; simple)
2052 5 (... deep or complicated)

However, you have some specific musculoskeletal codes for foreign body removal from some specific anatomical areas. In your case scenario, since your clinician removed the foreign body from the foot, you can use one of these codes for the FBR depending on the location and complexity of the procedure: