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removal of foreign body

  1. Default removal of foreign body
    Medical Coding Books
    Have not had this before would appreciate rules and regulations on a procedure done for removal of a of clip left in durring a procedure.

  2. #2
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    Quote Originally Posted by carol52 View Post
    Have not had this before would appreciate rules and regulations on a procedure done for removal of a of clip left in durring a procedure.
    Probably could use more information: how long ago was the original surgery, what part of the body, what insurance carrier? Is there a problem that is requiring the removal of the clip? Some clips are left on purpose and don't need removed unless there is a problem.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. Default
    The clip was retained from a previous gallbladder surgery from another facility. was left in the recutus muscle. was causing the pt some pain. Blue cross is the ins

  4. Default
    Without the actual documentation to determine appropriate coding...

    I would look at the 996.XX diagnosis code series to determine a code for complication of implant and look at 20670 or 20680 for the removal of an implant.

    Hope this helps!
    Tracey Thompson, CPC, CPPM

  5. #5
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    Tacoma, WA
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    Quote Originally Posted by carol52 View Post
    The clip was retained from a previous gallbladder surgery from another facility. was left in the recutus muscle. was causing the pt some pain. Blue cross is the ins
    Your original question was in regard to rules and regulations around this procedure. The rules are just the same as for any other surgical procedure. The insurance carrier will determine medical necessity based on the documentation. You may want to preauthorize this service for the patient.

    The code for the procedure will be whatever type of procedure the provider is planning to do, laparoscopic or open.

    The diagnosis codes should be first the symptoms the patient has related to the device, such as abdominal pain, and then the code to follow that is 996.59 Mechanical complication due to other implant and internal device, as this code points to non-absorbable surgical material NOS (surgical clip).

    Hope this helps!
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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