Wiki foreign body removal - sufficient to code

[ggparker14]

Can I get other opinions on whether this documentation would be sufficient to code a foreign body removal?

Body area: skin
General location: lower extremity
Local details: right foot
Anesthesia: local infiltration
Local anesthetic: lidocaine 1% withou epinephrine
Anesthetic: 6.5 ml
Localization method: probed
Removal mechanism: hemostat
Dressing: antibiotic ointment
Tendon involvement: non
Depth: sub-q
Complexity: 1 object
Objects recovered: glass piece
Post-procedure assessment: foreign body removed.

thank you for any help.

 

[salCCS]

rhblevins61@yahoo.com, please see below. I also attached a scenario to help you out


Per CPT Guidelines- if a foreign body is removed without an incision, it is included in the E/M.

Removal mechanism: hemostat

A 14-year-old male was fly fishing and accidentally got the fish hook stuck in the back of his hand. After being examined in the ED, the physician clipped the barbs off the protruding section of the fish hook and then pulled the hook out of the skin with a hemostat. The wound was irrigated, a dressing applied and the patient was discharged home. Which of the following codes would be appropriate for the case?

answer
No incision was made for this simple foreign body removal from the skin. Only ICD-9-CM 98.26 would be assigned. All other code choices require that an incision be made or that structures deeper than the skin be involved