Refresh Your Knowledge of Foreign Body Removals
Review the CMS guidelines to make sure you’re using 52000 correctly. When a patient presents for a foreign body removal procedure, meticulous attention to the case details is crucial for accurate coding. Factors like the object’s location, depth, the extraction technique, and the complexity of the closure all significantly influence the coding process. Together we’ll review the most common codes used for foreign body removals related to urology as well as dissect a real case study to sharpen your skills. Learn Common Codes for Foreign Body Removal Procedures The following are the codes most commonly used in foreign body removal procedures: This is the most appropriate code for a simple foreign body removal, such as a stent/calculus, via a cystoscope from within the normal urinary tract, when direct incision into deep tissues is not necessary. “This code is used in cases where the foreign body is easily accessible and does not require extra work,” says John Piaskowski, CPC-I, CPMA, CUC, CRC, CGSC, CGIC, CCC, CIRCC, CCVTC, COSC, specialty medicine auditor at Capital Health in Trenton, New Jersey. According to Piaskowski, “This code is most appropriate in situations where the removal of the foreign body is complicated by extra work such as a need for tract dilation, electrocautery, hemorrhage control, or complex manipulation of the foreign body.” “This code is most appropriate for the simple removal of a foreign body or stent/calculus from within the normal urinary tract via a cystoscope, but an indwelling ureteral stent needs to be inserted,” says Piaskowski. Review the Following Case Documentation Office visit: A 31-year-old patient who identifies as male presents with gross hematuria that started this morning and a self-inflicted and retained foreign object in the urethra. He is complaining of intense penile pain. He denies any abdominal pain, bruising, or bleeding anywhere else. The patient has had no fever, cough, chest pain, or shortness of breath. No blurred vision is reported. The patient has no nausea, vomiting, or diarrhea. They have no numbness, weakness, or tingling to their extremities. No acute anxiety or depression aren noted. Upon examination, the patient’s vital signs were reviewed and found to be normal. They alert and responded to questions slowly but appropriately. Their penis appeared inflamed, and their perineum was tender, though the scrotum was unaffected and normal. The assessment concluded a penile injury and possible septic infection. A cystoscopic foreign body removal was recommended, with the understanding that surgical repair might be necessary in the event of extensive penile tissue damage. The surgical risks were explained to the patient, and they agreed to proceed. Surgical procedure: I performed cystoscopy with a flexible cystoscope and a flexible ureteroscope until I identified the location of the foreign object, with external palpation and with the use of an ultrasound. I was able to identify the general vicinity of the foreign object embedded within the penile tissue/urethra. I created a vertical midline incision at the penoscrotal junction as the object is in the area of the distal bulbar urethra. Skin was incised with a #15 blade then subcutaneous tissues were dissected with use of Bovie, scissors, and blunt dissection where appropriate. I was on top of the urethra. The tissue planes were not cleared due to the inflammatory changes and induration of the tissue surrounding the urethra and the distal bulbar region. I placed a Foley catheter with the aid of a cystoscope and with palpation, I identified the midline of the area where the object was expected. I eventually cut over the object and made an opening about 3 cm into that open space. I was able to extract the object in 1 piece, and it was sent to pathology for identification. Some fluid was irrigated over the object and sent for wound culture. Urine culture was also sent at the beginning of the procedure. Understanding that the urethra is severely traumatized throughout the bulbar region, my goal was to close the opening we created into the space where the foreign object was. After removal of the object, the area was irrigated with Aricept thoroughly and I repeated that throughout all the steps of the closure. I used 5-0 polydioxanone (PDS) and closed the space where the foreign object was. I then reinforced that with another 5-0 PDS in a watertight fashion. I believe that its space was within the spongiosum of the bulbar urethra most likely. Good hemostasis was noted. I then closed the surgical field in multiple layers. First I used 2 layers with 4-0 PDS then I closed 2 layers with 3-0 Monocryl. I used Irrisept irrigation throughout each layer multiple times. I did not feel that it was appropriate to keep the wound open as majority of the tissues looked healthy other than where the object was dislodged and the immediate surrounding tissue. That being said, patient is at risk of infection, and we will keep them on broad-spectrum antibiotics. Local was injected and 4-0 Monocryl was used to close the wound in subcuticular fashion. I then reinforced the closure with 2-0 chromic in a running fashion. No concern for injuries to surrounding or penile structures. Good hemostasis. Choose the Correct Codes for the Scenario For the evaluation and management (E/M) portion, you would choose 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) with modifier 57 (Decision for surgery) attached to the E/M code. According to Piaskowski, the surgical procedure mentioned above should be coded using 54115. Make note: “Because the provider ultimately uses the cystoscope as a ‘scouting’ measure to determine the positioning of the foreign body, it is not a true diagnostic study,” he says. Due to this, you cannot add 52000 (Cystourethroscopy (separate procedure)) in addition to 54115, as the Centers for Medicare & Medicaid Services (CMS) guidelines “do not allow for reporting scout endoscopies when used for guidance,” says Piaskowski. For more information on this CMS guideline in the National Correct Coding Initiative (NCCI) manual, click here and refer to section C-13. Additionally, there will be multiple ICD-10-CM codes to add to the claim: Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
