Increase Your “Foreign Body Removal” Reimbursements

Most foreign body removal procedures are pretty black and white. Only on the rarest of occasions is there a complication and most of the claims can be handled in a similar manner. However in the even the physician is called on to perform soft tissue removal in a FBR procedure, you need to know how to code your medical billing claim s so your reimbursement won’t be paid only partially or denied. Make sure in this event you code the service with 10121 (Incision and removal of foreign body, subcutaneous tissues; complicated).

Some giveaways that the FBR procedure was more complex than normal will be found in notes and procedurs that show radiographic guidance was used. A complex soft-tissue FBR may also have localization techniques including use of a C-arm fluoroscopy device, ultrasound, or x-rays with radiographic markers and extensive dissection. All of these procedures are clues the FBR was more complex.

Consider this example:
A patient presents to the ER and says it feels as though “something is stuck” in his forearm. The ED physician performs a level-three ED E/M service and finds and attempt s to localize the found foreign body. On exam she can palpate something beneath the skin, but attempts to exact the location of the foreign body (including making an incision) fail. Under C-arm fluoroscopy guidance, the physician localizes a 1-cm foreign body, makes a small incision and removes the FB. The wound is left open and the patient is placed on antibiotics.

On the claim, you should:
* report 10121 for the complex FBR.
* append 913.6 (Superficial foreign body [splinter] without major open wound and without mention of infection; elbow, forearm and wrist) to 10121 to represent the FB.
* report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; moderate-complexity medical decision-making) for the E/M.
* append 959.3 (Injury; elbow, forearm, and wrist) to 99283 to represent the forearm injury.
* attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99283 to show that the E/M and FBR were separate services.

Meeting these requirements for a more complex service and showing the proper documentation will ensure that your complex FBR claims are reimbursed without question.

View all Articles by: Melissa Clark, CCS-P