Pediatric Coding Alert

Question: A pediatrician sees a patient in the office and removes a belly-button ring that was stuck in the wrong place. If she does not perform an incision and instead uses forceps to dislodge the ring, is billing a code for foreign-body removal correct? Which procedure and diagnosis codes should I use for the removal?

Colorado Subscriber

Answer: Foreign-body removal codes vary regarding their requirements. Depending on which body site the pediatrician removes the object from, she may have to perform an incision to bill the corresponding foreign-body removal code. For instance, to bill 10120* (Incision and removal of foreign body, subcutaneous tissues; simple), the physician makes a small incision in the skin overlying the foreign body and removes the object using hemostats or forceps. Or, a physician may remove a foreign body from the nasal area without incision and report 30300* (Removal foreign body, intranasal; office type procedure).

Although some coders think a small incision refers to a cut made with a knife, other coding experts and pediatricians maintain that probing with a hemostat or a sterile needle qualifies as a small incision. In this case, if your pediatrician uses an instrument to extensively probe the area prior to dislodging the ring with forceps, you may bill 10120.

If the pediatrician does not document any type of incision or probing, you should include the service in the E/M code for the visit (99201-99215, Office or other outpatient visit for the E/M of a new or established patient). Link the E/M service to 911.8 (Other and unspecified superficial injury of trunk, without mention of infection).