removal of fish hook from finger

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ggparker14

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Need other opinions on CPT(s). Not sure if this procedure is included with the E/M since it is a removal of foreign body?

Procedure reads: Area was anesthetized with one percent lidocaine plain digital and local block. Could not push the barb forward due to the other hooks. The barb was pulled back through the skin over the barb was nicked with number 11 scalpel and the hook came loose. No problems or complications. Tetanus shot was given.

Thanks for any help.
 
My understanding is that you cannot code a removal of FB w/o incision and the referenced note does not clearly indicate an incision... I code quite a few of these in our ER(the Land of 10,000 Lakes and at least 10 fish hooks in the hand on any summer weekend:) and include the procedure in the E/M if an incision is not clearly documented.
Have a great day.
 
I agree with PeaPod, if there is no documentation of an incision, we can't code the foreign body removal. We capture the time spend in the E&M level.
 
I would not have coded as a procedure because I didn't interpret "barb was nicked" as enough documentation to support an incision into the skin... It could be read and interpreted without further inquiry to mean he simply nicked the actual barb on the hook with the scalpel and made it easier to pull out??

Definitely one that would need clarification from the performing provider.
 
If the procedure note was posted exactly as documented, I would have asked for clarification on what was nicked. An instrument was noted so that tells me something was incised/cut. A simple, "Skin over the barb was nicked with a #11 scalpel..." would suffice. :)
 
Fishhok removal by pushing barb

Digital block of left finger with lidocaine 1% at the base of the metacarpal phalangeal joint betadine soak fishhook removed by pushing barn through skin cutting then pulling fishhook out ....can I code CPT for this or E/M is sufficient
 
I would code 10120 for this procedure. It is documented #11 scalpel used and moreover the hook was pushed thru and pulled out, sometimes the provider only makes an incision with a needle to remove FB. They only need to 'open' the skin, nothing is stated about size or sutures. To read some procedures they sound so simple but in reality the work is performed and it fits the CPT.
 
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