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Thread: Removal of Foreign Body

  1. #1

    Default Removal of Foreign Body

    AAPC: Back to School
    I'm getting 28192 for this procedure below. The hospital coder has 20103. Not sure who's right????

    Date: 01/05/12

    PREOPERATIVE DIAGNOSIS: Foreign body, left foot.

    POSTOPERATIVE DIAGNOSIS: Foreign body, left foot.

    PROCEDURE: Extract of foreign body, left foot, under fluoroscopy.

    ANESTHESIA: General.

    DESCRIPTION OF PROCEDURE: The patient was taken to the operative suite and
    placed in the supine position. Upon satisfactory general anesthesia, the
    patient's left lower extremity was prepped and draped in a sterile fashion.

    Along the lateral aspect of the left heel along the plantar skin was an
    obvious, healed, puncture site representing the site of entry of the foreign
    body. Under sonograph guidance an echodense structure was noted in the soft
    tissue and this was localized under sonograph guidance with a 20-gauge needle.
    Fluoroscopy was brought into the operative field and with 2 views, did
    confirm a foreign body in proximity to the tip of the 20-gauge needle.
    Lidocaine 1% with epinephrine was used as local anesthetic. A skin incision
    was carried out along the lateral aspect of the left heel overlying the site
    of the localized foreign body. Dissection was carried down sharply using the
    scalpel. Deep retraction was performed to expose the deep tissue.
    Fluoroscopy images were obtained to further aid in the localization of the
    foreign body. Ultimately with time it was discovered in the subcutaneous
    tissue. A 4 x 4 was placed and extracted and a foreign body was removed from
    the operative field. Fluoroscopic imaging showed no other radiopaque density
    within the foot. The foreign body was inspected and it did appear to be the
    barbed tip of a stingray which was consistent with the patient's history of
    having stepped on a stingray while walking in the surf on a beach in Bermuda
    at which point the child suffered the puncture wound.

    There was no significant bleeding noted. The skin was closed with interrupted
    4-0 Ethilon sutures. A sterile dressing was applied. The foreign body was
    given to the father. The patient was transported back to the recovery room in
    stable condition.

    DR LLL


  2. #2
    Join Date
    Apr 2007
    Nashville AAPC Chapter


    I am agreeing with you 28192.

    Foreign body, deep (retraction documented), foot - It's how if follows in the index and cross referenced code.

    20103 if for a penetrating wound like a gunshot or a stab wound, which this is not as it is clearly documented that the skin healed over the foreign body at one time.

  3. #3

    Default Cpt 20103 vs 28192

    Thanks for the help

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