Primary Care Coding Alert

Here's why you-ll use E/M codes for some foreign-body removal encounters Patients who report to your FP for foreign-body removal (FBR) present a challenge for coders. And with the summer months fast approaching, more outdoor work and play for your patients could mean a rush of FBRs for your FP. When your FP removes a foreign body from a patient's skin, including subcutaneous or accessory structures, you-ll typically code either 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (... complicated) for the encounter, depending on specifics. But in order to code your FBR encounters properly, you-ll need to know the difference between a simple and complicated FBR. Further, coders also need to know when a removal does not meet the clinical definition of FBR, because you-ll code these scenarios with an evaluation and management code instead.
Code Most Simple Splinter Removals With 10120 While the 10120 descriptor contains the term -simple,- CPT gives you no exact definition of a simple FBR, says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan. -It is a matter of interpretation,- he says, and offices have to decide for themselves what constitutes simple FBR. Freda Fontaine, director of coding/compliance for Plano, Texas-based Questcare Practice Management, considers an FBR to be simple when: the FP removes the FBR via simple incision overlying a foreign body embedded in subcutaneous tissue. the FBR requires minimal debridement and no dissection. Consider this example from Fontaine: A 34-year-old established female patient fell from a ladder while hanging a mirror. She presents complaining of arm and finger pain, multiple contusions of the upper arm and shoulder, and a glass splinter embedded beneath the skin on the right index finger. After taking an expanded problem-focused exam and an expanded problem-focused history, the FP makes a single incision over the FB site, permitting removal of the glass with splinter forceps. The area is then cleaned and secured with steri-strips. In this instance, the FP made a single incision and was able to close the FBR site without incident. This qualifies as a simple FBR. On the claim, report 10120 for the FBR. report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity) for the E/M service. append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99213 to show that it was a separate service from the FBR. link 923.09 (Contusion of [...]